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A physician documents a diagnosis using an outdated ICD code.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

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?

Accepted Answer

Timeliness

Answer

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?

Accepted Answer

Patient's insurance policy number

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

To identify missing or incomplete documentation in medical records

Answer

Deficiency analysis identifies gaps in documentation to ensure records are complete and legally compliant.

(CEHRS) Certified Electronic Health Records Specialist Practice Test