CPC Health Information & Data Content 3 — Questions and Answers
Question 1: What does the acronym 'EHR' stand for in the context of health information management?
- Electronic Health Record (Correct answer)
- Encoded Health Report
- Electronic Hospital Record
- Enhanced Health Registry
Correct answer: Electronic Health Record
EHR stands for Electronic Health Record, a digital version of a patient's paper chart that is real-time and patient-centered.
Question 2: Which section of the medical record documents a patient's subjective complaints, objective findings, clinical assessment, and treatment plan?
- SOAP note (Correct answer)
- Discharge summary
- Operative report
- Consultation report
Correct answer: SOAP note
A SOAP note organizes clinical documentation into Subjective, Objective, Assessment, and Plan sections.
Question 3: A 'late effect' or 'sequela' in ICD-10-CM coding refers to:
- A residual condition that remains after the acute phase of an illness or injury has resolved (Correct answer)
- A complication occurring during the same hospitalization
- An adverse effect of a properly administered drug
- A condition present at the time of admission
Correct answer: A residual condition that remains after the acute phase of an illness or injury has resolved
Sequela describes the residual condition or late effect that persists after the acute phase of the original illness or injury is resolved.
Question 4: Which type of health record release requires a signed patient authorization before disclosure?
- Release to the patient's attorney for litigation (Correct answer)
- Release to treating providers for continuity of care
- Release to a public health authority for disease reporting
- Release ordered by a court subpoena
Correct answer: Release to the patient's attorney for litigation
Releasing records to an attorney for litigation requires a signed patient authorization because it is not a routine treatment, payment, or operations purpose.
Question 5: In CPT coding, what is the significance of a 'semicolon' (;) in a code description?
- The portion before the semicolon is shared by the parent code and all indented codes below it (Correct answer)
- It separates two unrelated procedures
- It indicates a bundled service
- It marks an add-on code
Correct answer: The portion before the semicolon is shared by the parent code and all indented codes below it
In CPT, the common descriptor before the semicolon applies to the parent code and all indented child codes that follow.
Question 6: Which data quality characteristic ensures that health data is recorded at or near the time the care was provided?
- Timeliness (Correct answer)
- Accuracy
- Completeness
- Consistency
Correct answer: Timeliness
Timeliness means data is recorded promptly after the care event to ensure relevance and reliability.
Question 7: The 'Minimum Necessary' standard under HIPAA requires covered entities to:
- Limit disclosure of PHI to the minimum amount necessary to accomplish the intended purpose (Correct answer)
- Provide complete records whenever any PHI is requested
- Share all information with any healthcare provider
- Disclose only information older than 10 years
Correct answer: Limit disclosure of PHI to the minimum amount necessary to accomplish the intended purpose
The Minimum Necessary standard limits PHI disclosures to only what is needed to accomplish the specific purpose of the request.
CPC Health Information & Data Content 3
What does the acronym 'EHR' stand for in the context of health information management?