CKE Clinical Documentation and Health Records 2 — Questions and Answers
Question 1: Under HIPAA, patients generally have the right to access their medical records within how many days?
- 7 days
- 15 days
- 30 days (Correct answer)
- 60 days
Correct answer: 30 days
HIPAA requires covered entities to provide patients access to their medical records within 30 days of the request.
Question 2: What is an EHR (Electronic Health Record)?
- A paper-based backup of patient charts
- A digital version of a patient's medical history maintained by providers (Correct answer)
- A patient-controlled health journal
- A billing database only
Correct answer: A digital version of a patient's medical history maintained by providers
An EHR is a real-time, digital version of a patient's medical history that is maintained by one or more healthcare providers.
Question 3: What is the difference between an EHR and a PHR?
- EHR is maintained by providers; PHR is maintained by patients (Correct answer)
- PHR is more detailed than an EHR
- EHR is used only in hospitals; PHR is used in clinics
- PHR is the legal medical record; EHR is for billing
Correct answer: EHR is maintained by providers; PHR is maintained by patients
An EHR is maintained by healthcare providers, while a PHR (Personal Health Record) is maintained and controlled by the patient.
Question 4: Which document authorizes the release of a patient's medical records to a third party?
- Advance directive
- HIPAA Notice of Privacy Practices
- Release of Information authorization form (Correct answer)
- Insurance pre-authorization form
Correct answer: Release of Information authorization form
A Release of Information authorization form is required by HIPAA before disclosing protected health information to a third party.
Question 5: What does the term 'late entry' mean in medical documentation?
- An entry added after a scheduled documentation deadline
- Documentation entered after the event occurred but still necessary for accurate records (Correct answer)
- Entries made after a patient is discharged
- Any note written after midnight
Correct answer: Documentation entered after the event occurred but still necessary for accurate records
A late entry is documentation added after the event it describes, which must be clearly labeled as a late entry with the date and time it was added.
Question 6: Which section of the medical record contains the physician's working explanation of a patient's condition?
- Nursing assessment
- Diagnosis and problem list (Correct answer)
- Discharge summary
- Consent forms
Correct answer: Diagnosis and problem list
The diagnosis and problem list contains the physician's working diagnosis or list of identified patient health problems.
CKE Clinical Documentation and Health Records 2
Under HIPAA, patients generally have the right to access their medical records within how many days?