Ambulatory Care Test Documentation and Health Records 1

Question 1

Which federal law primarily governs the privacy and security of patient health information in US ambulatory care settings?

Accepted Answer

HIPAA

Answer

EMTALA

Answer

HITECH Act

Answer

ADA

Question 2

In an ambulatory care electronic health record (EHR), which entry type allows a provider to borrow and build upon a prior note without creating an entirely new assessment?

Accepted Answer

Copy forward

Answer

Addendum

Answer

Cosignature

Answer

Attestation

Question 3

A patient requests a copy of their medical records. Under HIPAA, the covered entity must provide access within how many days?

Accepted Answer

30 days

Answer

10 days

Answer

60 days

Answer

90 days

Question 4

Which of the following constitutes a HIPAA breach requiring patient notification?

Accepted Answer

A locked laptop containing PHI is stolen

Answer

Sharing records with another treating provider

Answer

Discussing a patient case in a private provider meeting

Answer

Sending a patient their own lab results

Question 5

What does the acronym SOAP stand for in ambulatory care documentation?

Accepted Answer

Subjective, Objective, Assessment, Plan

Answer

Signs, Observations, Actions, Procedures

Answer

Summary, Outcomes, Analysis, Progress

Answer

Symptoms, Orders, Assessments, Plans

Question 6

Which documentation element is required when a provider corrects an error in an EHR note?

Accepted Answer

Add an addendum with the correct information and date/time/signature

Answer

Delete the original entry and retype the correct information

Answer

Strike through the error, add a correction, and date/initial it

Answer

Mark the entry as invalid without adding any explanation