AHIMA Health Records Management 3 — Questions and Answers
Question 1: Under the HIPAA Security Rule, which of the following is classified as a required implementation specification?
- Encryption of data in transit
- Workforce security training
- Assigned security responsibility (Correct answer)
- Automatic logoff
Correct answer: Assigned security responsibility
Assigning a security official (security responsibility) is a required implementation specification under the HIPAA Security Rule's administrative safeguards.
Question 2: Which record-keeping practice best supports the admissibility of an electronic health record in court?
- Printing and notarizing all entries
- Maintaining a reliable audit trail showing who entered or modified data (Correct answer)
- Storing records only on encrypted USB drives
- Having the treating physician certify each entry weekly
Correct answer: Maintaining a reliable audit trail showing who entered or modified data
An audit trail demonstrating consistent, accurate record-keeping practices supports the business records exception and EHR admissibility.
Question 3: A subpoena duces tecum requires a healthcare facility to:
- Provide oral testimony about a patient's care
- Produce documents or records specified in the court order (Correct answer)
- Appear in court to answer questions under oath
- Certify that no relevant records exist
Correct answer: Produce documents or records specified in the court order
A subpoena duces tecum ('bring with you') compels the production of specified records or documents for legal proceedings.
Question 4: Which quantitative analysis component ensures that all required forms and reports are present in the medical record?
- Authentication check
- Content review (Correct answer)
- Record completion check
- Transcription verification
Correct answer: Content review
Content review in quantitative analysis verifies that all required forms, reports, and elements are present in the health record.
Question 5: What is the correct action when an error is discovered in a paper-based medical record?
- Use correction fluid (white-out) to cover the error neatly
- Draw a single line through the error, date, and initial it (Correct answer)
- Remove the page and rewrite it accurately
- Delete the entry and write 'error' in the margin
Correct answer: Draw a single line through the error, date, and initial it
The correct method is to draw a single line through the error, add the date and initials, and write the correct information—never obliterate the original entry.
Question 6: Which law grants patients born after August 1975 the right to inspect their own federal education records, but is often confused with healthcare privacy rules?
- FERPA (Correct answer)
- HIPAA
- HITECH
- COPPA
Correct answer: FERPA
FERPA (Family Educational Rights and Privacy Act) governs educational records, not health records, though student health records at schools may fall under its scope.
Question 7: A hospital's record retention policy must account for which special population that may require extended retention beyond standard adult periods?
- Patients over age 65
- Minor patients, whose records are often retained until they reach the age of majority plus the standard retention period (Correct answer)
- Patients with chronic conditions
- Patients who paid out-of-pocket
Correct answer: Minor patients, whose records are often retained until they reach the age of majority plus the standard retention period
Records for minors are typically retained until the patient reaches the age of majority plus the standard retention period, to preserve their future rights.
AHIMA Health Records Management 3
Under the HIPAA Security Rule, which of the following is classified as a required implementation specification?