RHIT Record Content Management 3

Question 1

Which element is required for a valid informed consent document in a health record?

Accepted Answer

Description of risks, benefits, and alternatives of the procedure

Answer

Witness must be a licensed nurse

Answer

Patient's insurance information

Answer

Attending physician's countersignature within 24 hours

Question 2

A facility's incomplete record rate is consistently above benchmark. Which policy change would MOST directly address this problem?

Accepted Answer

Implement suspension of clinical privileges for physicians with delinquent records

Answer

Increase the number of HIM staff assigned to coding

Answer

Require nurses to complete physician documentation

Answer

Reduce the legal medical record definition

Question 3

What does the term 'legal health record' refer to?

Accepted Answer

The subset of health information defined by the organization as the official business record

Answer

Records subpoenaed for court proceedings

Answer

All data stored in the EHR including drafts and metadata

Answer

Records protected by attorney-client privilege

Question 4

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?

Accepted Answer

The entry must be labeled as a late entry with the current date and time of documentation

Answer

The entry should be deleted and re-entered with today's date only

Answer

A supervisor must co-sign the late entry

Answer

The entry is inadmissible and must be excluded from the record

Question 5

Under the HIPAA Minimum Necessary standard, a request for PHI from another treating provider should be:

Accepted Answer

Limited to only the information reasonably needed to accomplish the treatment purpose

Answer

Denied unless the patient is present to authorize

Answer

Honored with the full record since treatment is a permitted purpose

Answer

Routed through the hospital's legal department first

Question 6

Which accreditation body publishes the Comprehensive Accreditation Manual for Hospitals (CAMH) which includes medical record standards?

Accepted Answer

The Joint Commission (TJC)

Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

National Committee for Quality Assurance (NCQA)

Answer

American Health Information Management Association (AHIMA)

Question 7

A patient requests to amend their health record, claiming a diagnosis is incorrect. The provider reviews and disagrees. What should the facility do?

Accepted Answer

Deny the amendment but add the patient's statement of disagreement to the record

Answer

Correct the record as requested to avoid legal liability

Answer

Deny the request and provide no further action

Answer

Transfer the record to another provider for a second opinion