CEHRS Clinical Documentation Management 5

Question 1

A healthcare facility discovers that a former employee accessed records of patients they never treated. This situation represents a violation of:

Accepted Answer

The minimum necessary standard under HIPAA

Answer

HIPAA's minimum necessary standard prohibits accessing PHI beyond what is needed to perform one's job duties.

Question 2

Which of the following is a key difference between a problem-oriented medical record (POMR) and a source-oriented medical record (SOMR)?

Accepted Answer

POMR organizes information by clinical problem; SOMR organizes by department or provider type

Answer

POMR groups documentation around each identified clinical problem, while SOMR organizes records by the source such as nursing, lab, or radiology.

Question 3

A patient's advance directive documented in the medical record indicates they do not want resuscitation. A nurse notices the DNR order is missing. The best action is to:

Accepted Answer

Notify the physician immediately to obtain a written DNR order

Answer

An advance directive communicates patient wishes but a valid physician-signed DNR order must be present for clinical staff to withhold resuscitation.

Question 4

Which format is most commonly used for structuring clinical notes, particularly in physician documentation?

Accepted Answer

SOAP (Subjective, Objective, Assessment, Plan)

Answer

The SOAP format is the standard structure for clinical notes, organizing documentation into subjective findings, objective data, assessment, and plan.

Question 5

When a patient's legal guardian requests access to a minor's psychiatric records, the facility should:

Accepted Answer

Consult state law, as minors may have privacy rights for certain sensitive records

Answer

State laws often grant minors the right to consent to and control access to certain sensitive records such as mental health, substance abuse, and reproductive health.

(CEHRS) Certified Electronic Health Records Specialist Practice Test

(CEHRS) Certified Electronic Health Records Specialist Practice Test

CEHRS Clinical Documentation Management 5