CEHRS Clinical Documentation Management 2

Question 1

A physician documents a diagnosis using an outdated ICD code. What is the medical record specialist's most appropriate action?

Accepted Answer

Query the physician and flag the entry for correction

Answer

Accept the code since the physician is the authority

Answer

Correct the code independently without notifying anyone

Answer

Delete the entry and ask the physician to re-document

Question 2

Which documentation principle ensures that entries are recorded as events occur rather than being backdated?

Accepted Answer

Timeliness

Answer

Accuracy

Answer

Completeness

Answer

Legibility

Question 3

Under HIPAA, which of the following is NOT a required element in an authorization to release medical records?

Accepted Answer

Patient's insurance policy number

Answer

Description of information to be disclosed

Answer

Expiration date or event

Answer

Purpose of the disclosure

Question 4

A late entry added to a medical record should include which of the following to maintain documentation integrity?

Accepted Answer

The current date, time, and a note indicating it is a late entry

Answer

The original date of service only

Answer

No date so as not to confuse the record

Answer

Only the clinician's signature

Question 5

Which of the following best describes the purpose of a deficiency analysis in health information management?

Accepted Answer

To identify missing or incomplete documentation in medical records

Answer

To audit billing codes for accuracy

Answer

To review patient satisfaction surveys

Answer

To schedule follow-up appointments for patients

Question 6

A patient requests an amendment to their medical record. The covered entity may deny the request if:

Accepted Answer

The record was not created by the covered entity

Answer

The patient does not provide a written reason

Answer

The information is older than five years

Answer

The amendment would improve clarity

Question 7

Which term describes the legal concept that medical records are owned by the healthcare facility but the information belongs to the patient?

Accepted Answer

Dual ownership doctrine

Answer

Chain of custody

Answer

Custodial stewardship

Answer

Proprietary interest