AHIMA Health Records Management 2 — Questions and Answers
Question 1: Which federal regulation establishes the minimum necessary standard for sharing protected health information (PHI)?
- HITECH Act
- HIPAA Privacy Rule (Correct answer)
- CMS Conditions of Participation
- Joint Commission Standards
Correct answer: HIPAA Privacy Rule
The HIPAA Privacy Rule requires that only the minimum necessary amount of PHI be used or disclosed to accomplish the intended purpose.
Question 2: A patient requests amendment of their medical record because they believe a diagnosis is incorrect. Under HIPAA, the covered entity may deny the request if:
- The record was created more than 6 months ago
- The provider who created the record is no longer employed there
- The information was not created by the covered entity (Correct answer)
- The patient has previously requested an amendment
Correct answer: The information was not created by the covered entity
HIPAA permits denial of an amendment request if the covered entity did not create the information and the originating source is still available.
Question 3: Which retention schedule should a hospital apply when state law requires records to be kept 7 years but HIPAA mandates 6 years?
- Follow HIPAA's 6-year requirement as the federal standard
- Follow the state law's 7-year requirement (Correct answer)
- Use whichever is shorter to reduce storage costs
- Consult the Joint Commission for a ruling
Correct answer: Follow the state law's 7-year requirement
When state law imposes a longer retention period than HIPAA, facilities must comply with the more stringent state requirement.
Question 4: What is the primary purpose of a deficiency analysis in health information management?
- To identify billing errors before claim submission
- To track incomplete or missing documentation in medical records (Correct answer)
- To evaluate physician credentialing compliance
- To audit coding accuracy for DRG assignment
Correct answer: To track incomplete or missing documentation in medical records
Deficiency analysis identifies incomplete, missing, or unsigned documentation so that records can be completed within required timeframes.
Question 5: Which document grants a specific individual the legal authority to make healthcare decisions for an incapacitated patient?
- Living will
- Do-not-resuscitate order
- Durable power of attorney for healthcare (Correct answer)
- Advance beneficiary notice
Correct answer: Durable power of attorney for healthcare
A durable power of attorney for healthcare designates a healthcare proxy or agent to make medical decisions when the patient cannot.
Question 6: An HIM professional discovers that a physician has been signing blank medical record forms to be completed later by residents. This practice is:
- Acceptable if the physician countersigns within 24 hours
- A violation of medical record integrity standards (Correct answer)
- Permitted under Joint Commission safe harbor provisions
- Required when residents lack independent credentials
Correct answer: A violation of medical record integrity standards
Signing blank records is fraudulent and violates medical record integrity, authentication standards, and federal anti-fraud regulations.
Question 7: The legal health record (LHR) differs from the designated record set (DRS) in that the LHR:
- Includes administrative financial data used for payment decisions
- Is defined by the organization for business and legal purposes (Correct answer)
- Must encompass all data used to make patient care decisions
- Is determined solely by HIPAA regulations
Correct answer: Is defined by the organization for business and legal purposes
The LHR is defined by each organization to identify records disclosed for legal proceedings, while the DRS is a broader HIPAA concept covering records used in care or payment decisions.
AHIMA Health Records Management 2
Which federal regulation establishes the minimum necessary standard for sharing protected health information (PHI)?