Record Content Management Flashcards
7 cards from real RHIT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Record Content Management flashcards as text
Which element is required for a valid informed consent document in a health record?
Answer: Description of risks, benefits, and alternatives of the procedure
Valid informed consent must include the nature of the procedure, its risks, benefits, and alternatives so the patient can make a voluntary decision.
A facility's incomplete record rate is consistently above benchmark. Which policy change would MOST directly address this problem?
Answer: Implement suspension of clinical privileges for physicians with delinquent records
Suspending clinical privileges for physicians with delinquent records is the most effective enforcement mechanism recognized by accreditation bodies.
What does the term 'legal health record' refer to?
Answer: The subset of health information defined by the organization as the official business record
The legal health record is the organization-defined subset of health information that constitutes its official business record for legal and disclosure purposes.
A record is flagged because a physician's late entry was added three days after service. What is required to maintain the integrity of this late entry?
Answer: The entry must be labeled as a late entry with the current date and time of documentation
Late entries must be clearly labeled as such, with the actual date and time of documentation noted, while also referencing the date of service.
Under the HIPAA Minimum Necessary standard, a request for PHI from another treating provider should be:
Answer: Limited to only the information reasonably needed to accomplish the treatment purpose
Even for permitted treatment purposes, the Minimum Necessary standard requires limiting disclosure to what is reasonably needed for that specific purpose.
Which accreditation body publishes the Comprehensive Accreditation Manual for Hospitals (CAMH) which includes medical record standards?
Answer: The Joint Commission (TJC)
The Joint Commission publishes the CAMH, which sets medical record content and completion standards for accredited hospitals.
A patient requests to amend their health record, claiming a diagnosis is incorrect. The provider reviews and disagrees. What should the facility do?
Answer: Deny the amendment but add the patient's statement of disagreement to the record
Under HIPAA, if an amendment is denied, the patient has the right to submit a statement of disagreement that must be appended to the record.