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
Which method is recommended for permanently destroying paper medical records containing PHI?
Answer: Cross-cut shredding or incineration
Cross-cut shredding or incineration ensures that PHI on paper cannot be reconstructed and is the HIPAA-compliant disposal method.
An EHR audit trail is important because it:
Answer: Records who accessed or modified a patient record and when
An audit trail logs all access and changes to electronic health records, providing accountability and supporting compliance investigations.
What is the standard retention period for adult patient medical records under most US state guidelines?
Answer: 5 to 10 years after last visit or last date of service
Most states require adult medical records to be retained for 5 to 10 years from the date of last service, though requirements vary by state.
Which of the following situations requires a written authorization from the patient before releasing PHI?
Answer: Sending records to the patient's attorney for a personal injury lawsuit
Disclosing PHI to an attorney for legal purposes (such as a personal injury lawsuit) requires specific written patient authorization.
In medical record documentation, what is the correct way to make an error correction in a paper record?
Answer: Draw a single line through the error, write the correct information, date it, and initial it
A single line through the error preserves the original entry for legal integrity, while the correction, date, and initials show who made the change and when.
What is a 'release of information' (ROI) log used for in a medical office?
Answer: Tracking all disclosures of PHI to document compliance
An ROI log tracks every instance of PHI disclosure, documenting who requested the information, what was sent, and when, to demonstrate HIPAA compliance.
Which federal act gives patients the right to request an accounting of disclosures of their PHI?
Answer: The Health Insurance Portability and Accountability Act (HIPAA)
HIPAA grants patients the right to request an accounting of certain disclosures of their PHI made by a covered entity over the past six years.