CEHRS Clinical Documentation Management 2 — Questions and Answers
Question 1: A physician documents a diagnosis using an outdated ICD code. What is the medical record specialist's most appropriate action?
- Accept the code since the physician is the authority
- Query the physician and flag the entry for correction (Correct answer)
- Correct the code independently without notifying anyone
- Delete the entry and ask the physician to re-document
Correct answer: Query the physician and flag the entry for correction
The specialist should query the physician to clarify and correct the entry while maintaining documentation integrity.
Question 2: Which documentation principle ensures that entries are recorded as events occur rather than being backdated?
- Accuracy
- Timeliness (Correct answer)
- Completeness
- Legibility
Correct answer: Timeliness
Timeliness requires that documentation be completed promptly after the care or event occurs.
Question 3: Under HIPAA, which of the following is NOT a required element in an authorization to release medical records?
- Description of information to be disclosed
- Expiration date or event
- Patient's insurance policy number (Correct answer)
- Purpose of the disclosure
Correct answer: Patient's insurance policy number
HIPAA authorizations require specific elements including description of PHI, purpose, and expiration, but not an insurance policy number.
Question 4: A late entry added to a medical record should include which of the following to maintain documentation integrity?
- The original date of service only
- The current date, time, and a note indicating it is a late entry (Correct answer)
- No date so as not to confuse the record
- Only the clinician's signature
Correct answer: The current date, time, and a note indicating it is a late entry
Late entries must be clearly identified with the actual date and time of entry and labeled as a late entry.
Question 5: Which of the following best describes the purpose of a deficiency analysis in health information management?
- To identify missing or incomplete documentation in medical records (Correct answer)
- To audit billing codes for accuracy
- To review patient satisfaction surveys
- To schedule follow-up appointments for patients
Correct answer: To identify missing or incomplete documentation in medical records
Deficiency analysis identifies gaps in documentation to ensure records are complete and legally compliant.
Question 6: A patient requests an amendment to their medical record. The covered entity may deny the request if:
- The patient does not provide a written reason
- The record was not created by the covered entity (Correct answer)
- The information is older than five years
- The amendment would improve clarity
Correct answer: The record was not created by the covered entity
A covered entity may deny an amendment request if it did not create the record and is not the appropriate custodian to amend it.
Question 7: Which term describes the legal concept that medical records are owned by the healthcare facility but the information belongs to the patient?
- Chain of custody
- Dual ownership doctrine (Correct answer)
- Custodial stewardship
- Proprietary interest
Correct answer: Dual ownership doctrine
The dual ownership doctrine holds that facilities own the physical record while patients have ownership rights over the information within it.
CEHRS Clinical Documentation Management 2
A physician documents a diagnosis using an outdated ICD code.
What is the medical record specialist's most appropriate action?