CHL Documentation and Record Keeping 2 — Questions and Answers
Question 1: Under HIPAA, how long must a covered entity retain its privacy policies and procedures?
- 3 years from creation or last effective date
- 6 years from creation or last effective date (Correct answer)
- 10 years from creation or last effective date
- Indefinitely
Correct answer: 6 years from creation or last effective date
HIPAA requires covered entities to retain documentation of privacy policies and procedures for 6 years from the date of creation or the date it was last in effect, whichever is later.
Question 2: Which of the following best describes the purpose of a 'problem-oriented medical record' (POMR)?
- Organizes records alphabetically by diagnosis
- Structures documentation around a numbered list of patient problems (Correct answer)
- Focuses exclusively on the patient's chief complaint
- Separates clinical notes from billing records
Correct answer: Structures documentation around a numbered list of patient problems
A problem-oriented medical record (POMR) organizes patient information around a numbered, prioritized list of problems, facilitating comprehensive and coordinated care.
Question 3: A healthcare leader discovers that a nurse has been documenting vital signs before actually taking them. This practice is an example of:
- Retrospective charting
- Fraudulent documentation (Correct answer)
- Prospective documentation
- Addendum entry
Correct answer: Fraudulent documentation
Charting vital signs before they are measured constitutes fraudulent documentation, which can compromise patient safety and expose the organization to legal liability.
Question 4: Which document serves as the primary legal record in a malpractice case involving patient care?
- Incident report
- Medical record (Correct answer)
- Quality improvement report
- Staffing log
Correct answer: Medical record
The medical record is the primary legal document used in malpractice litigation because it reflects the care provided, clinical decisions made, and patient responses.
Question 5: What is the recommended approach when a physician disagrees with a nursing note in the medical record?
- Delete the nursing note and rewrite it
- Add an addendum with the physician's perspective (Correct answer)
- Strike through the nursing note with initials
- File a formal grievance and leave the record unchanged
Correct answer: Add an addendum with the physician's perspective
The appropriate response is to add a dated, signed addendum expressing the physician's perspective; altering or deleting existing entries is prohibited.
Question 6: In healthcare documentation, 'concurrent review' refers to:
- Reviewing records after patient discharge
- Evaluating documentation while the patient is still receiving care (Correct answer)
- Auditing records from the prior fiscal year
- Comparing records across multiple facilities simultaneously
Correct answer: Evaluating documentation while the patient is still receiving care
Concurrent review involves evaluating the medical record and care appropriateness while the patient is actively receiving services, enabling real-time corrections and utilization management.
Question 7: Which federal law governs the electronic transmission of healthcare information and requires specific transaction standards?
- EMTALA
- HITECH Act
- HIPAA Administrative Simplification provisions (Correct answer)
- Stark Law
Correct answer: HIPAA Administrative Simplification provisions
The HIPAA Administrative Simplification provisions establish national standards for electronic healthcare transactions, code sets, and unique identifiers to streamline data exchange.
CHL Documentation and Record Keeping 2
Under HIPAA, how long must a covered entity retain its privacy policies and procedures?