CHL Documentation and Record Keeping 2

Question 1

Under HIPAA, how long must a covered entity retain its privacy policies and procedures?

Accepted Answer

6 years from creation or last effective date

Answer

3 years from creation or last effective date

Answer

10 years from creation or last effective date

Answer

Indefinitely

Question 2

Which of the following best describes the purpose of a 'problem-oriented medical record' (POMR)?

Accepted Answer

Structures documentation around a numbered list of patient problems

Answer

Organizes records alphabetically by diagnosis

Answer

Focuses exclusively on the patient's chief complaint

Answer

Separates clinical notes from billing records

Question 3

A healthcare leader discovers that a nurse has been documenting vital signs before actually taking them. This practice is an example of:

Accepted Answer

Fraudulent documentation

Answer

Retrospective charting

Answer

Prospective documentation

Answer

Addendum entry

Question 4

Which document serves as the primary legal record in a malpractice case involving patient care?

Accepted Answer

Medical record

Answer

Incident report

Answer

Quality improvement report

Answer

Staffing log

Question 5

What is the recommended approach when a physician disagrees with a nursing note in the medical record?

Accepted Answer

Add an addendum with the physician's perspective

Answer

Delete the nursing note and rewrite it

Answer

Strike through the nursing note with initials

Answer

File a formal grievance and leave the record unchanged

Question 6

In healthcare documentation, 'concurrent review' refers to:

Accepted Answer

Evaluating documentation while the patient is still receiving care

Answer

Reviewing records after patient discharge

Answer

Auditing records from the prior fiscal year

Answer

Comparing records across multiple facilities simultaneously

Question 7

Which federal law governs the electronic transmission of healthcare information and requires specific transaction standards?

Accepted Answer

HIPAA Administrative Simplification provisions

Answer

EMTALA

Answer

HITECH Act

Answer

Stark Law