Medical Scribe Compliance & HIPAA Regulations Flashcards

A physician asks a scribe to copy and paste a previous visit note into today's encounter without changes. This practice is problematic primarily because:

Answer: It may constitute medical record fraud and inaccurate documentation

Copy-pasting prior notes without updating them can result in inaccurate, misleading medical records and may constitute fraud or cloning.

Under HIPAA, patients have the right to request that their PHI not be disclosed to a health plan for treatment they paid for out-of-pocket. This right is called:

Answer: Right to restrict disclosures

Patients who pay out-of-pocket in full may request the covered entity restrict disclosure of that PHI to health plans, and the covered entity must comply.

A medical scribe accidentally sends a fax containing PHI to the wrong number. What is the FIRST step?

Answer: Notify the HIPAA Privacy Officer and follow the facility's breach protocol

Any potential breach must be reported to the Privacy Officer immediately so the facility can assess the breach and follow proper notification procedures.

Which of the following represents a required physical safeguard under the HIPAA Security Rule?

Answer: Implementing workstation use policies for computers accessing ePHI

Workstation use policies are a required physical safeguard that specify the functions to be performed, manner of use, and physical surroundings of workstations accessing ePHI.

The HITECH Act strengthened HIPAA primarily by:

Answer: Extending HIPAA requirements directly to business associates and increasing penalties

The HITECH Act made business associates directly liable under HIPAA and significantly increased civil and criminal penalties for violations.

When a patient is incapacitated and their spouse requests medical information, a covered entity may share information only if:

Answer: The disclosure is in the patient's best interest and the spouse is involved in their care

HIPAA allows disclosure to a family member involved in a patient's care when the patient is incapacitated, based on professional judgment that it is in the patient's best interest.

Which statement about electronic health record (EHR) audit logs is most accurate?

Answer: Audit logs track who accessed ePHI, when, and what actions were taken

EHR audit logs record user activity including who accessed patient records, timestamps, and actions taken, supporting HIPAA's accountability requirements.