Documentation & Record Keeping Flashcards

A patient requests an amendment to their medical record. The covered entity denies the request. What documentation is required?

Answer: A written denial statement must be provided and retained

When denying an amendment request, the covered entity must provide a written denial to the individual and retain documentation of the denial and the basis for it.

Under HIPAA, what must a covered entity document when an individual requests an accounting of disclosures?

Answer: Disclosures made for purposes other than TPO for the prior 6 years

The accounting of disclosures covers disclosures made for purposes other than treatment, payment, and healthcare operations (TPO) going back 6 years from the date of the request.

What information must be captured in each entry of an accounting of disclosures log?

Answer: Date, name and address of recipient, description of PHI disclosed, and purpose of disclosure

Each accounting entry must include the date of disclosure, the name and address of the recipient entity or person, a description of the PHI disclosed, and a statement of the purpose.

A covered entity provides the same type of disclosure to multiple individuals in a 90-day period. How may accounting entries be maintained?

Answer: A single summary entry may be used for disclosures of the same type during that period

For repetitive disclosures of the same type within a 90-day period, HIPAA permits a summary accounting entry covering all such disclosures rather than individual entries for each.

Which type of disclosure is NOT required to be included in an accounting of disclosures?

Answer: Disclosures for treatment, payment, and healthcare operations (TPO)

Disclosures for treatment, payment, and healthcare operations are expressly excluded from the accounting requirement, along with disclosures to the individual themselves.

A hospital must provide an accounting of disclosures to a patient. What is the standard timeframe for fulfilling this request?

Answer: 30 days, with one 30-day extension if needed

A covered entity must act on an accounting of disclosures request within 60 days, and may extend the deadline by 30 days if it provides a written statement with the reason and expected completion date.

When an individual submits multiple accounting of disclosures requests within a 12-month period, when can the covered entity charge a fee?

Answer: The first request within a 12-month period must be free; fees may apply to subsequent requests

The first accounting of disclosures within a 12-month period must be provided free of charge; the covered entity may impose a reasonable, cost-based fee for additional requests within that period after notifying the individual.