RHIT Record Content Management 5

Question 1

Which of the following is the BEST example of secondary use of health record data?

Accepted Answer

A researcher using de-identified patient data to study disease trends

Answer

A physician reviewing a patient's allergy list before prescribing

Answer

A nurse documenting vital signs during a patient's visit

Answer

A pharmacist verifying a medication order

Question 2

What is a key difference between the designated record set (DRS) and the legal health record?

Accepted 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

Answer

The DRS is used only for billing purposes

Answer

The legal health record includes all metadata and audit logs; the DRS does not

Answer

There is no difference; the terms are interchangeable under HIPAA

Question 3

A patient's records are requested via subpoena. The HIM professional should FIRST:

Accepted Answer

Consult with the facility's legal counsel before releasing any information

Answer

Release the records immediately to comply with the court order

Answer

Obtain a written patient authorization before proceeding

Answer

Notify the patient's insurance company of the subpoena

Question 4

Which document type is used by a physician to transfer the responsibility for a patient's care to another physician within the same facility?

Accepted Answer

Transfer note

Answer

Discharge summary

Answer

Referral letter

Answer

Consultation report

Question 5

Under the HIPAA Privacy Rule, which of the following does NOT require patient authorization for disclosure?

Accepted Answer

Disclosure to a public health authority for disease reporting

Answer

Disclosure to a life insurance company for underwriting

Answer

Disclosure to a marketing firm for promotional purposes

Answer

Disclosure to an employer for pre-employment screening

Question 6

A facility's record destruction policy calls for shredding paper records. Which additional step is required to properly document this process?

Accepted Answer

Maintaining a certificate of destruction that lists what was destroyed, when, and by whom

Answer

Notifying each patient whose records are destroyed

Answer

Obtaining court approval before destroying any records

Answer

Archiving a photocopy of each destroyed record

Question 7

Which of the following is a characteristic of the problem-oriented medical record (POMR)?

Accepted Answer

Care is organized around a numbered problem list with SOAP-format progress notes

Answer

Documents are organized by the department that created them

Answer

All entries are arranged in reverse chronological order

Answer

Records are maintained exclusively in electronic format