AHIMA Health Records Management 4

Question 1

Which release of information scenario requires a valid written authorization from the patient?

Accepted Answer

Releasing records to the patient's employer for occupational health purposes

Answer

Disclosing records to a treating specialist for continuing care

Answer

Sending records to a public health authority for disease reporting

Answer

Providing records to law enforcement for a gunshot wound report

Question 2

What distinguishes a problem-oriented medical record (POMR) from a source-oriented medical record (SOMR)?

Accepted Answer

POMR organizes information by clinical problem; SOMR organizes by department or source of information

Answer

POMR is used only in outpatient settings; SOMR is used only in hospitals

Answer

POMR requires electronic format; SOMR allows paper only

Answer

POMR uses ICD codes; SOMR uses CPT codes

Question 3

Under the Medicare Conditions of Participation, a medical record must be completed within how many days following patient discharge?

Accepted Answer

30 days

Answer

14 days

Answer

60 days

Answer

90 days

Question 4

A patient calls to request copies of their medical records. Under HIPAA, the covered entity must provide access within:

Accepted Answer

30 calendar days, with one 30-day extension if needed

Answer

15 calendar days, with one 15-day extension if needed

Answer

60 calendar days, with no extensions allowed

Answer

72 hours for all requests regardless of complexity

Question 5

Which term describes the process of ensuring that a health record accurately reflects the patient's actual condition and the care provided?

Accepted Answer

Qualitative analysis

Answer

Quantitative analysis

Answer

Concurrent review

Answer

Prospective review

Question 6

What does the term 'authentication' mean in the context of health records?

Accepted Answer

Verifying the author's identity and confirming they are responsible for an entry

Answer

Encrypting a record so only authorized users can view it

Answer

Converting a paper record into electronic format

Answer

Auditing a record for compliance with coding guidelines

Question 7

Which health record component serves as the primary tool for communicating a patient's ongoing care plan among members of the interdisciplinary care team?

Accepted Answer

Physician's orders

Answer

Face sheet (patient registration form)

Answer

Discharge summary

Answer

Master patient index