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 of the following is the BEST example of secondary use of health record data?
Answer: A researcher using de-identified patient data to study disease trends
Secondary use refers to using health data for purposes other than direct patient care, such as research, quality improvement, or public health reporting.
What is a key difference between the designated record set (DRS) and the legal health record?
Answer: The DRS is broader and includes records used to make decisions about an individual; the legal health record is the organization's defined official record
The DRS, defined by HIPAA, is a broader set of records used in decision-making, while the legal health record is the facility-defined official business record.
A patient's records are requested via subpoena. The HIM professional should FIRST:
Answer: Consult with the facility's legal counsel before releasing any information
The HIM professional should consult legal counsel first, as a subpoena alone may not override state privacy protections without a court order.
Which document type is used by a physician to transfer the responsibility for a patient's care to another physician within the same facility?
Answer: Transfer note
A transfer note documents the reason for and details of transferring a patient's care from one physician to another, including within the same facility.
Under the HIPAA Privacy Rule, which of the following does NOT require patient authorization for disclosure?
Answer: Disclosure to a public health authority for disease reporting
Disclosures to public health authorities for mandated disease reporting are a permitted use under HIPAA that does not require patient authorization.
A facility's record destruction policy calls for shredding paper records. Which additional step is required to properly document this process?
Answer: Maintaining a certificate of destruction that lists what was destroyed, when, and by whom
A certificate of destruction provides a legal record that documents the destruction process, protecting the facility from liability.
Which of the following is a characteristic of the problem-oriented medical record (POMR)?
Answer: Care is organized around a numbered problem list with SOAP-format progress notes
The POMR uses a numbered problem list as an index, and progress notes are written in SOAP (Subjective, Objective, Assessment, Plan) format for each problem.