Medical Records Management Flashcards
7 cards from real CMAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medical Records Management flashcards as text
Under HIPAA, which of the following is NOT considered protected health information (PHI)?
Answer: Aggregated de-identified statistical data
Properly de-identified and aggregated statistical data does not qualify as PHI because it cannot be used to identify an individual.
What is the purpose of a 'chart deficiency' notice sent to a physician?
Answer: To alert the physician that required documentation is incomplete or missing
A chart deficiency notice informs the physician that specific documentation required for a complete medical record has not been completed.
Which record storage system arranges files so that the last two digits of the patient ID determine the primary filing location?
Answer: Terminal digit filing
Terminal digit filing uses the last two (or more) digits of the ID as the primary sort key, distributing files evenly across shelves.
A patient requests a copy of their medical record but asks that the information NOT be sent to their insurer. What must the practice do?
Answer: Honor the request and restrict disclosure to the insurer
Under HIPAA, patients have the right to request restrictions on how their PHI is disclosed, and the practice must agree to reasonable restrictions.
What does the term 'legal health record' (LHR) refer to?
Answer: The subset of health information that constitutes the official business record for legal and disclosure purposes
The legal health record is the designated set of documents that represent the official record of patient care and is used for legal, regulatory, and disclosure purposes.
Which of the following best describes the 'minimum necessary' standard under HIPAA?
Answer: Releasing only the PHI reasonably needed to accomplish the intended purpose
The minimum necessary standard requires covered entities to make reasonable efforts to disclose only the PHI needed for the specific purpose of the disclosure.
A medical office receives a subpoena for a patient's records. What is the FIRST step the administrative assistant should take?
Answer: Notify the physician and consult the office's legal counsel before releasing records
The administrative assistant should notify the treating physician and involve legal counsel to ensure proper authorization and compliance before releasing any records.