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

Valid informed consent must include the nature of the procedure, its risks, benefits, and alternatives so the patient can make a voluntary decision.

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

Suspending clinical privileges for physicians with delinquent records is the most effective enforcement mechanism recognized by accreditation bodies.

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

The legal health record is the organization-defined subset of health information that constitutes its official business record for legal and disclosure purposes.

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

Late entries must be clearly labeled as such, with the actual date and time of documentation noted, while also referencing the date of service.

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

Even for permitted treatment purposes, the Minimum Necessary standard requires limiting disclosure to what is reasonably needed for that specific purpose.

RHIT - Registered Health Information Technician Practice Test

RHIT - Registered Health Information Technician Practice Test

RHIT Record Content Management 3