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

Disclosure to an employer generally requires written patient authorization because it falls outside the permitted uses for treatment, payment, and operations.

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

The POMR organizes entries around numbered patient problems, while the SOMR groups information by the type or source of service (e.g., lab, radiology, nursing).

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

CMS Conditions of Participation require that a hospital's medical records be completed within 30 days of patient discharge.

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

HIPAA requires covered entities to act on access requests within 30 calendar days, with one 30-day extension allowed if the entity notifies the individual.

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

Qualitative analysis evaluates whether the clinical content of the record is complete, accurate, and consistent with the patient's condition and care.

(AHIMA) American Health Information Management Association Practice Test

(AHIMA) American Health Information Management Association Practice Test

AHIMA Health Records Management 4