Health Information Management Flashcards
6 cards from real Certified Coding Associate Exam practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Information Management flashcards as text
Which of the following is considered the primary purpose of the health record?
Answer: Patient care documentation and continuity of care
The primary purpose of the health record is to document patient care and support continuity of care among healthcare providers.
What does the term 'legal health record' refer to?
Answer: The official business record of a healthcare organization used in legal proceedings
The legal health record is the official business record of a healthcare organization that can be used as evidence in legal proceedings.
Which of the following is an example of protected health information (PHI) under HIPAA?
Answer: A patient's name combined with their diagnosis
PHI includes individually identifiable health information, such as a patient's name combined with their medical condition or diagnosis.
The minimum necessary standard under HIPAA requires covered entities to:
Answer: Use or disclose only the minimum PHI needed to accomplish the intended purpose
The minimum necessary standard requires that only the least amount of PHI needed to accomplish the task be used or disclosed.
What is the primary function of a Release of Information (ROI) process?
Answer: To manage and control the disclosure of patient health information
The ROI process ensures patient health information is disclosed appropriately, with proper authorization and in compliance with laws and regulations.
Which accreditation organization sets standards for hospitals including health information management practices?
Answer: The Joint Commission (TJC)
The Joint Commission (TJC) is a major accrediting body that sets standards for hospital operations including medical record management.