Patient Assessment & Clinical Evaluation Flashcards
7 cards from real CHP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Clinical Evaluation flashcards as text
A patient undergoing a substance abuse assessment at a federally assisted program has records protected by which regulation in addition to HIPAA?
Answer: 42 CFR Part 2
42 CFR Part 2 provides additional protections for substance use disorder (SUD) patient records at federally assisted programs, often stricter than HIPAA.
A covered entity's clinical assessment system undergoes a security upgrade. Under HIPAA, the audit logs of who accessed patient evaluation records must be retained for at least:
Answer: 6 years
HIPAA requires covered entities to retain documentation of policies, procedures, and security measures for six years from creation or last effective date.
An employer asks a covered entity for the results of a job applicant's pre-employment clinical evaluation. The covered entity may disclose this information:
Answer: Only with a valid written authorization from the applicant
Disclosing clinical assessment results to an employer requires a valid HIPAA-compliant written authorization from the individual.
A patient's clinical evaluation was conducted at Hospital A. When the patient transfers care to Hospital B, Hospital A's disclosure of the evaluation records is:
Answer: Permitted as a treatment disclosure without authorization
Disclosing PHI to another provider for treatment continuity is a permitted Treatment disclosure under HIPAA's TPO framework.
Under HIPAA, a patient who believes their clinical assessment record contains an error has the right to:
Answer: Request an amendment to the record
The Privacy Rule grants individuals the right to request amendments to their PHI in a designated record set, though the covered entity may deny the request in certain circumstances.
A covered entity sends a patient's clinical assessment summary to a billing company for claim submission. The billing company is best described as:
Answer: A business associate requiring a BAA
A billing company that handles PHI on behalf of a covered entity is a business associate and must have a signed Business Associate Agreement (BAA) in place.
A clinician documents a patient's mental status examination findings in the EHR. Under HIPAA, this information is classified as:
Answer: Protected Health Information (PHI)
Mental status exam findings are individually identifiable health information maintained by a covered entity, meeting the definition of PHI under HIPAA.