AHIMA RHIA Exam with Questions and
Correct Answers Latest 2025-2026
GRADED A+
17. ,A ,patient ,requests ,copies ,of ,her ,medical ,records ,in ,an ,electronic ,format. ,The
,hospital ,maintains ,a ,portion ,of ,the ,designated ,record ,set ,in ,a ,paper ,format ,and ,a
,portion ,of ,the ,designated ,record ,set ,in ,an ,electronic ,format. ,How ,should ,the ,hospital
,respond?
a. ,Provide ,the ,records ,in ,paper ,format ,only
b. ,Scan ,the ,paper ,documents ,so ,that ,all ,records ,can ,be ,sent ,electronically
c. ,Provide ,the ,patient ,with ,both ,paper ,and ,electronic ,copies ,of ,the ,record
d. ,Inform ,the ,patient ,that ,PHI ,cannot ,be ,sent ,electronically ,- ,CORRECT ,ANSWER-c.
,Provide ,the ,patient ,with ,both ,paper ,and ,electronic ,copies ,of ,the ,record
The ,HIPAA ,Privacy ,Rule ,states ,that ,the ,covered ,entity ,must ,provide ,individuals ,with
,their ,information ,in ,the ,form ,that ,is ,requested ,by ,the ,individuals, ,if ,it ,is ,readily
,producible ,in ,the ,requested ,format. ,The ,covered ,entity ,can ,certainly ,decide, ,along
,with ,the ,individual, ,the ,easiest ,and ,least ,expensive ,way ,to ,provide ,the ,copies ,they
,request. ,Per ,the ,request ,of ,an ,individual, ,a ,covered ,entity ,must ,provide ,an ,electronic
,copy ,of ,any ,and ,all ,health ,information ,that ,the ,covered ,entity ,maintains ,electronically
,in ,a ,designated ,record ,set. ,If ,a ,covered ,entity ,does ,not ,maintain ,the ,entire
,designated ,record ,set ,electronically, ,there ,is ,not ,a ,requirement ,that ,the ,covered
,entity ,scan ,paper ,documents ,so ,the ,documents ,can ,be ,delivered ,electronically
,(Thomason ,2013, ,102).
15. ,For ,an ,EHR ,to ,provide ,robust ,clinical ,decision ,support, ,what ,critical ,element ,must
,be ,present?
a. ,Structured ,data
b. ,Internet ,connection
c. ,Physician ,portal
d. ,Standard ,vocabulary ,- ,CORRECT ,ANSWER-If ,an ,EHR ,is ,to ,provide ,clinical
,decision ,support ,it ,requires ,two ,things: ,structured ,data ,and ,a ,clinical ,data ,repository
,(Sandefer ,2016a, ,364).
,14. ,Which ,of ,the ,following ,is ,considered ,a ,two-factor ,authentication ,system?
a. ,User ,ID ,and ,password
b. ,User ,ID ,and ,voice ,scan
c. ,Password ,and ,swipe ,card
d. ,Password ,and ,PIN ,- ,CORRECT ,ANSWER-c. ,Password ,and ,swipe ,card
The ,three ,methods ,of ,two-factor ,authentication ,are ,something ,you ,know, ,such ,as ,a
,password ,or ,PIN; ,something ,you ,have, ,such ,as ,an ,ATM ,card, ,token, ,or ,swipe/smart
,card; ,and ,something ,you ,are, ,such ,as ,a ,biometric ,fingerprint, ,voice ,scan, ,iris, ,or
,retinal ,scan ,(Sayles ,and ,Trawick ,2014, ,219).
Under ,RBRVS, ,which ,elements ,are ,used ,to ,calculate ,a ,Medicare ,payment?
a. ,Work ,value ,and ,extent ,of ,the ,physical ,exam
b. ,Malpractice ,expenses ,and ,detail ,of ,the ,patient ,history
c. ,Work ,value ,and ,practice ,expenses
d. ,Practice ,expenses ,and ,review ,of ,systems ,- ,CORRECT ,ANSWER-Each ,Resource-
Based ,Relative ,Value ,Scale ,(RBRVS) ,comprises ,three ,elements: ,physician ,work,
,physician ,practice ,expense, ,and ,malpractice, ,each ,of ,which ,is ,a ,national ,average
,available ,in ,the ,Federal ,Register ,(Casto ,and ,Forrestal ,2015, ,150).
12. ,The ,predefined ,process ,icon ,is ,used ,in ,flowcharting ,to ,indicate:
a. ,A ,process ,in ,which ,actions ,are ,being ,performed ,by ,humans
b. ,A ,point ,in ,the ,process ,at ,which ,participants ,must ,evaluate ,the ,status ,of ,the
,process
c. ,Formal ,procedures ,that ,participants ,are ,expected ,to ,carry ,out ,the ,same ,way ,every
,time
d. ,A ,point ,in ,the ,process ,at ,which ,the ,participants ,must ,record ,data ,in ,paper-based
,or ,computer- ,based ,formats ,- ,CORRECT ,ANSWER-The ,rectangle ,with ,double ,lines
,on ,the ,side ,in ,a ,flowchart ,is ,a ,predefined ,process ,icon. ,This ,symbol ,represents ,the
,formal ,procedure ,that ,participants ,are ,expected ,to ,carry ,out ,the ,same ,way ,every ,time
,(Shaw ,and ,Carter ,2015, ,198).
. ,A ,researcher ,mined ,the ,Medicare ,Provider ,Analysis ,Review ,(MEDPAR) ,file. ,The
,analysis ,revealed ,trends ,in ,lengths ,of ,stay ,for ,rural ,hospitals. ,What ,type ,of
,investigation ,was ,the ,researcher ,conducting?
a. ,Content ,analysis
b. ,Effect ,size ,review
c. ,Psychometric ,assay
d. ,Secondary ,analysis ,- ,CORRECT ,ANSWER-Secondary ,analysis ,is ,the ,analysis ,of
,the ,original ,work ,of ,others. ,In ,secondary ,analysis, ,researchers ,reanalyze ,original
,data ,by ,combining ,data ,sets ,to ,answer ,new ,questions ,or ,by ,using ,more ,sophisticated
,,statistical ,techniques. ,The ,work ,of ,others ,created ,the ,MEDPAR ,file ,(Forrestal ,2016,
,586).
In ,reviewing ,a ,patient ,chart, ,the ,coder ,finds ,that ,the ,patient's ,chest ,x-ray ,is
,suggestive ,of ,chronic ,obstructive ,pulmonary ,disease ,(COPD). ,The ,attending
,physician ,mentions ,the ,x-ray ,finding ,in ,one ,progress ,note, ,but ,no ,medication,
,treatment, ,or ,further ,evaluation ,is ,provided. ,Which ,of ,the ,following ,actions ,should ,the
,coder ,take ,in ,this ,case?
a. ,Query ,the ,attending ,physician ,and ,ask ,him ,to ,validate ,a ,diagnosis ,based ,on ,the
,chest ,x-ray ,results
b. ,Code ,COPD ,because ,the ,documentation ,substantiates ,it
c. ,Query ,the ,radiologist ,to ,determine ,whether ,the ,patient ,has ,COPD
d. ,Assign ,a ,code ,from ,the ,abnormal ,findings ,to ,reflect ,the ,condition ,- ,CORRECT
,ANSWER-A ,query ,is ,routine ,communication ,and ,education ,tool ,used ,to ,advocate ,for
,complete ,and ,compliant ,documentation. ,The ,intent ,is ,to ,clarify ,what ,has ,been
,recorded, ,not ,to ,call ,into ,question ,the ,provider's ,clinical ,judgment ,or ,medical
,expertise. ,This ,is ,an ,example ,of ,a ,circumstance ,where ,the ,chronic ,condition ,must ,be
,verified. ,All ,secondary ,conditions ,must ,match ,the ,definition ,in ,the ,UHDDS ,and
,whether ,the ,COPD ,does ,is ,not ,clear ,(Hunt ,2016, ,276-277).
Per ,the ,HITECH ,breach ,notification ,requirements, ,which ,of ,the ,following ,is ,the
,threshold ,in ,which ,the ,media ,and ,the ,Secretary ,of ,Health ,and ,Human ,Services
,should ,be ,notified ,of ,the ,breach?
a. ,more ,than ,1,000 ,individuals ,affected
b. ,more ,than ,500 ,individuals ,affected
c. ,more ,than ,250 ,individuals ,affected
d. ,Any ,number ,of ,individuals ,affected ,requires ,notification ,- ,CORRECT ,ANSWER-
Reporting ,requirements ,mandate ,notification ,to ,the ,individual ,whose ,information ,was
,breached, ,and ,in ,the ,case ,of ,breaches ,of ,more ,than ,500 ,individuals' ,information, ,to
,the ,media ,and ,the ,Secretary ,of ,Health ,and ,Human ,Services ,(Biedermann ,and
,Dolezel ,2017, ,401).
Determining ,costs ,associated ,with ,EHR ,hardware ,and ,software ,acquisition,
,implementation, ,and ,ongoing ,maintenance ,represents ,which ,type ,of ,analysis?
a. ,Benefits ,realization ,study
b. ,Goal-setting ,exercise
c. ,Cost-benefit ,feasibility ,study
d. ,Productivity ,improvement ,study ,- ,CORRECT ,ANSWER-Cost-benefit ,feasibility ,is
,used ,to ,determine ,if ,an ,EHR ,initiative ,is ,appropriate ,for ,the ,organization ,at ,this ,time;
,it ,measures ,the ,costs ,associated ,with ,acquisition ,of ,hardware ,and ,software,
,installation, ,implementation, ,and ,ongoing ,maintenance ,(Amatayakul ,2016, ,104-105).
, Part ,of ,the ,coding ,supervisor's ,responsibility ,is ,to ,review ,accounts ,that ,have ,not ,been
,final ,billed ,due ,to ,errors. ,One ,of ,the ,accounts ,on ,the ,list ,is ,a ,same-day ,procedure.
,Upon ,review, ,the ,coding ,supervisor ,notices ,that ,the ,charge ,code ,on ,the ,bill ,was
,hard-coded. ,The ,ambulatory ,procedure ,coder ,added ,the ,same ,CPT ,code ,to ,the
,abstract. ,How ,should ,this ,error ,be ,corrected?
a. ,Delete ,the ,code ,from ,the ,CDM ,because ,it ,should ,not ,be ,there.
b. ,Refer ,the ,case ,to ,the ,chargemaster ,coordinator.
c. ,Force ,a ,final ,bill ,on ,the ,accounts ,since ,the ,duplication ,will ,not ,affect ,the ,UB-04.
d. ,Remove ,the ,code ,from ,the ,abstract ,and ,counsel ,the ,coder ,regarding ,CDM ,hard
,codes ,in ,this ,service. ,- ,CORRECT ,ANSWER-If ,a ,service ,is ,hard-coded ,into ,the
,charge ,description ,master ,(CDM), ,it ,is ,important ,that ,this ,decision ,is ,communicated
,to ,the ,coding ,staff. ,If ,the ,decision ,is ,not ,effectively ,communicated, ,the ,result ,could
,be ,duplicate ,billing ,that ,in ,turn ,could ,result ,in ,overpayment ,to ,the ,facility ,(Casto ,and
,Forrestal ,2015, ,253).
Which ,health ,record ,format ,is ,arranged ,in ,chronological ,order ,with ,documentation
,from ,various ,sources ,intermingled?
a. ,Electronic
b. ,Source-oriented
c. ,Problem-oriented
d. ,Integrated ,- ,CORRECT ,ANSWER-The ,integrated ,health ,record ,is ,arranged ,so ,that
,the ,documentation ,from ,various ,sources ,is ,intermingled ,and ,follows ,a ,strict
,chronological ,or ,reverse-chronological ,order. ,The ,advantage ,of ,the ,integrated ,format
,is ,that ,it ,is ,easy ,for ,caregivers ,to ,follow ,the ,course ,of ,the ,patient's ,diagnosis ,and
,treatment ,(Russo ,2013b, ,305).
The ,Medical ,Record ,Committee ,is ,reviewing ,the ,privacy ,policies ,for ,a ,large ,outpatient
,clinic. ,One ,of ,the ,members ,of ,the ,committee ,remarks ,that ,he ,feels ,that ,the ,clinic's
,practice ,of ,calling ,out ,a ,patient's ,full ,name ,in ,the ,waiting ,room ,is ,not ,in ,compliance
,with ,HIPAA ,regulations ,and ,that ,only ,the ,patient's ,first ,name ,should ,be ,used. ,Other
,committee ,members ,disagree ,with ,this ,assessment. ,What ,should ,the ,HIM ,director
,advise ,the ,committee?
a. ,HIPAA ,does ,not ,allow ,a ,patient's ,name ,to ,be ,announced ,in ,a ,waiting ,room.
b. ,There ,is ,no ,violation ,of ,HIPAA ,in ,announcing ,a ,patient's ,name, ,but ,the ,committee
,may ,want ,to ,consider ,implementing ,practices ,that ,might ,reduce ,this ,practice.
c. ,HIPAA ,allows ,only ,the ,use ,of ,the ,patient's ,first ,name.
d. ,HIPAA ,requires ,that ,patients ,be ,given ,numbers ,and ,that ,only ,the ,number ,be
,announced. ,- ,CORRECT ,ANSWER-The ,HIPAA ,Privacy ,Rule ,allows ,communications
,to ,occur ,for ,treatment ,purposes. ,The ,preamble ,repeatedly ,states ,the ,intent ,of ,the
,rule ,is ,not ,to ,interfere ,with ,customary ,and ,necessary ,communications ,in ,the
,healthcare ,of ,the ,individual. ,Calling ,out ,a ,patient's ,name ,in ,a ,waiting ,room, ,or ,even
,on ,the ,facility's ,paging ,system, ,is ,considered ,an ,incidental ,disclosure ,and, ,therefore,
,allowed ,in ,the ,Privacy ,Rule ,(Thomason ,2013, ,37).
Correct Answers Latest 2025-2026
GRADED A+
17. ,A ,patient ,requests ,copies ,of ,her ,medical ,records ,in ,an ,electronic ,format. ,The
,hospital ,maintains ,a ,portion ,of ,the ,designated ,record ,set ,in ,a ,paper ,format ,and ,a
,portion ,of ,the ,designated ,record ,set ,in ,an ,electronic ,format. ,How ,should ,the ,hospital
,respond?
a. ,Provide ,the ,records ,in ,paper ,format ,only
b. ,Scan ,the ,paper ,documents ,so ,that ,all ,records ,can ,be ,sent ,electronically
c. ,Provide ,the ,patient ,with ,both ,paper ,and ,electronic ,copies ,of ,the ,record
d. ,Inform ,the ,patient ,that ,PHI ,cannot ,be ,sent ,electronically ,- ,CORRECT ,ANSWER-c.
,Provide ,the ,patient ,with ,both ,paper ,and ,electronic ,copies ,of ,the ,record
The ,HIPAA ,Privacy ,Rule ,states ,that ,the ,covered ,entity ,must ,provide ,individuals ,with
,their ,information ,in ,the ,form ,that ,is ,requested ,by ,the ,individuals, ,if ,it ,is ,readily
,producible ,in ,the ,requested ,format. ,The ,covered ,entity ,can ,certainly ,decide, ,along
,with ,the ,individual, ,the ,easiest ,and ,least ,expensive ,way ,to ,provide ,the ,copies ,they
,request. ,Per ,the ,request ,of ,an ,individual, ,a ,covered ,entity ,must ,provide ,an ,electronic
,copy ,of ,any ,and ,all ,health ,information ,that ,the ,covered ,entity ,maintains ,electronically
,in ,a ,designated ,record ,set. ,If ,a ,covered ,entity ,does ,not ,maintain ,the ,entire
,designated ,record ,set ,electronically, ,there ,is ,not ,a ,requirement ,that ,the ,covered
,entity ,scan ,paper ,documents ,so ,the ,documents ,can ,be ,delivered ,electronically
,(Thomason ,2013, ,102).
15. ,For ,an ,EHR ,to ,provide ,robust ,clinical ,decision ,support, ,what ,critical ,element ,must
,be ,present?
a. ,Structured ,data
b. ,Internet ,connection
c. ,Physician ,portal
d. ,Standard ,vocabulary ,- ,CORRECT ,ANSWER-If ,an ,EHR ,is ,to ,provide ,clinical
,decision ,support ,it ,requires ,two ,things: ,structured ,data ,and ,a ,clinical ,data ,repository
,(Sandefer ,2016a, ,364).
,14. ,Which ,of ,the ,following ,is ,considered ,a ,two-factor ,authentication ,system?
a. ,User ,ID ,and ,password
b. ,User ,ID ,and ,voice ,scan
c. ,Password ,and ,swipe ,card
d. ,Password ,and ,PIN ,- ,CORRECT ,ANSWER-c. ,Password ,and ,swipe ,card
The ,three ,methods ,of ,two-factor ,authentication ,are ,something ,you ,know, ,such ,as ,a
,password ,or ,PIN; ,something ,you ,have, ,such ,as ,an ,ATM ,card, ,token, ,or ,swipe/smart
,card; ,and ,something ,you ,are, ,such ,as ,a ,biometric ,fingerprint, ,voice ,scan, ,iris, ,or
,retinal ,scan ,(Sayles ,and ,Trawick ,2014, ,219).
Under ,RBRVS, ,which ,elements ,are ,used ,to ,calculate ,a ,Medicare ,payment?
a. ,Work ,value ,and ,extent ,of ,the ,physical ,exam
b. ,Malpractice ,expenses ,and ,detail ,of ,the ,patient ,history
c. ,Work ,value ,and ,practice ,expenses
d. ,Practice ,expenses ,and ,review ,of ,systems ,- ,CORRECT ,ANSWER-Each ,Resource-
Based ,Relative ,Value ,Scale ,(RBRVS) ,comprises ,three ,elements: ,physician ,work,
,physician ,practice ,expense, ,and ,malpractice, ,each ,of ,which ,is ,a ,national ,average
,available ,in ,the ,Federal ,Register ,(Casto ,and ,Forrestal ,2015, ,150).
12. ,The ,predefined ,process ,icon ,is ,used ,in ,flowcharting ,to ,indicate:
a. ,A ,process ,in ,which ,actions ,are ,being ,performed ,by ,humans
b. ,A ,point ,in ,the ,process ,at ,which ,participants ,must ,evaluate ,the ,status ,of ,the
,process
c. ,Formal ,procedures ,that ,participants ,are ,expected ,to ,carry ,out ,the ,same ,way ,every
,time
d. ,A ,point ,in ,the ,process ,at ,which ,the ,participants ,must ,record ,data ,in ,paper-based
,or ,computer- ,based ,formats ,- ,CORRECT ,ANSWER-The ,rectangle ,with ,double ,lines
,on ,the ,side ,in ,a ,flowchart ,is ,a ,predefined ,process ,icon. ,This ,symbol ,represents ,the
,formal ,procedure ,that ,participants ,are ,expected ,to ,carry ,out ,the ,same ,way ,every ,time
,(Shaw ,and ,Carter ,2015, ,198).
. ,A ,researcher ,mined ,the ,Medicare ,Provider ,Analysis ,Review ,(MEDPAR) ,file. ,The
,analysis ,revealed ,trends ,in ,lengths ,of ,stay ,for ,rural ,hospitals. ,What ,type ,of
,investigation ,was ,the ,researcher ,conducting?
a. ,Content ,analysis
b. ,Effect ,size ,review
c. ,Psychometric ,assay
d. ,Secondary ,analysis ,- ,CORRECT ,ANSWER-Secondary ,analysis ,is ,the ,analysis ,of
,the ,original ,work ,of ,others. ,In ,secondary ,analysis, ,researchers ,reanalyze ,original
,data ,by ,combining ,data ,sets ,to ,answer ,new ,questions ,or ,by ,using ,more ,sophisticated
,,statistical ,techniques. ,The ,work ,of ,others ,created ,the ,MEDPAR ,file ,(Forrestal ,2016,
,586).
In ,reviewing ,a ,patient ,chart, ,the ,coder ,finds ,that ,the ,patient's ,chest ,x-ray ,is
,suggestive ,of ,chronic ,obstructive ,pulmonary ,disease ,(COPD). ,The ,attending
,physician ,mentions ,the ,x-ray ,finding ,in ,one ,progress ,note, ,but ,no ,medication,
,treatment, ,or ,further ,evaluation ,is ,provided. ,Which ,of ,the ,following ,actions ,should ,the
,coder ,take ,in ,this ,case?
a. ,Query ,the ,attending ,physician ,and ,ask ,him ,to ,validate ,a ,diagnosis ,based ,on ,the
,chest ,x-ray ,results
b. ,Code ,COPD ,because ,the ,documentation ,substantiates ,it
c. ,Query ,the ,radiologist ,to ,determine ,whether ,the ,patient ,has ,COPD
d. ,Assign ,a ,code ,from ,the ,abnormal ,findings ,to ,reflect ,the ,condition ,- ,CORRECT
,ANSWER-A ,query ,is ,routine ,communication ,and ,education ,tool ,used ,to ,advocate ,for
,complete ,and ,compliant ,documentation. ,The ,intent ,is ,to ,clarify ,what ,has ,been
,recorded, ,not ,to ,call ,into ,question ,the ,provider's ,clinical ,judgment ,or ,medical
,expertise. ,This ,is ,an ,example ,of ,a ,circumstance ,where ,the ,chronic ,condition ,must ,be
,verified. ,All ,secondary ,conditions ,must ,match ,the ,definition ,in ,the ,UHDDS ,and
,whether ,the ,COPD ,does ,is ,not ,clear ,(Hunt ,2016, ,276-277).
Per ,the ,HITECH ,breach ,notification ,requirements, ,which ,of ,the ,following ,is ,the
,threshold ,in ,which ,the ,media ,and ,the ,Secretary ,of ,Health ,and ,Human ,Services
,should ,be ,notified ,of ,the ,breach?
a. ,more ,than ,1,000 ,individuals ,affected
b. ,more ,than ,500 ,individuals ,affected
c. ,more ,than ,250 ,individuals ,affected
d. ,Any ,number ,of ,individuals ,affected ,requires ,notification ,- ,CORRECT ,ANSWER-
Reporting ,requirements ,mandate ,notification ,to ,the ,individual ,whose ,information ,was
,breached, ,and ,in ,the ,case ,of ,breaches ,of ,more ,than ,500 ,individuals' ,information, ,to
,the ,media ,and ,the ,Secretary ,of ,Health ,and ,Human ,Services ,(Biedermann ,and
,Dolezel ,2017, ,401).
Determining ,costs ,associated ,with ,EHR ,hardware ,and ,software ,acquisition,
,implementation, ,and ,ongoing ,maintenance ,represents ,which ,type ,of ,analysis?
a. ,Benefits ,realization ,study
b. ,Goal-setting ,exercise
c. ,Cost-benefit ,feasibility ,study
d. ,Productivity ,improvement ,study ,- ,CORRECT ,ANSWER-Cost-benefit ,feasibility ,is
,used ,to ,determine ,if ,an ,EHR ,initiative ,is ,appropriate ,for ,the ,organization ,at ,this ,time;
,it ,measures ,the ,costs ,associated ,with ,acquisition ,of ,hardware ,and ,software,
,installation, ,implementation, ,and ,ongoing ,maintenance ,(Amatayakul ,2016, ,104-105).
, Part ,of ,the ,coding ,supervisor's ,responsibility ,is ,to ,review ,accounts ,that ,have ,not ,been
,final ,billed ,due ,to ,errors. ,One ,of ,the ,accounts ,on ,the ,list ,is ,a ,same-day ,procedure.
,Upon ,review, ,the ,coding ,supervisor ,notices ,that ,the ,charge ,code ,on ,the ,bill ,was
,hard-coded. ,The ,ambulatory ,procedure ,coder ,added ,the ,same ,CPT ,code ,to ,the
,abstract. ,How ,should ,this ,error ,be ,corrected?
a. ,Delete ,the ,code ,from ,the ,CDM ,because ,it ,should ,not ,be ,there.
b. ,Refer ,the ,case ,to ,the ,chargemaster ,coordinator.
c. ,Force ,a ,final ,bill ,on ,the ,accounts ,since ,the ,duplication ,will ,not ,affect ,the ,UB-04.
d. ,Remove ,the ,code ,from ,the ,abstract ,and ,counsel ,the ,coder ,regarding ,CDM ,hard
,codes ,in ,this ,service. ,- ,CORRECT ,ANSWER-If ,a ,service ,is ,hard-coded ,into ,the
,charge ,description ,master ,(CDM), ,it ,is ,important ,that ,this ,decision ,is ,communicated
,to ,the ,coding ,staff. ,If ,the ,decision ,is ,not ,effectively ,communicated, ,the ,result ,could
,be ,duplicate ,billing ,that ,in ,turn ,could ,result ,in ,overpayment ,to ,the ,facility ,(Casto ,and
,Forrestal ,2015, ,253).
Which ,health ,record ,format ,is ,arranged ,in ,chronological ,order ,with ,documentation
,from ,various ,sources ,intermingled?
a. ,Electronic
b. ,Source-oriented
c. ,Problem-oriented
d. ,Integrated ,- ,CORRECT ,ANSWER-The ,integrated ,health ,record ,is ,arranged ,so ,that
,the ,documentation ,from ,various ,sources ,is ,intermingled ,and ,follows ,a ,strict
,chronological ,or ,reverse-chronological ,order. ,The ,advantage ,of ,the ,integrated ,format
,is ,that ,it ,is ,easy ,for ,caregivers ,to ,follow ,the ,course ,of ,the ,patient's ,diagnosis ,and
,treatment ,(Russo ,2013b, ,305).
The ,Medical ,Record ,Committee ,is ,reviewing ,the ,privacy ,policies ,for ,a ,large ,outpatient
,clinic. ,One ,of ,the ,members ,of ,the ,committee ,remarks ,that ,he ,feels ,that ,the ,clinic's
,practice ,of ,calling ,out ,a ,patient's ,full ,name ,in ,the ,waiting ,room ,is ,not ,in ,compliance
,with ,HIPAA ,regulations ,and ,that ,only ,the ,patient's ,first ,name ,should ,be ,used. ,Other
,committee ,members ,disagree ,with ,this ,assessment. ,What ,should ,the ,HIM ,director
,advise ,the ,committee?
a. ,HIPAA ,does ,not ,allow ,a ,patient's ,name ,to ,be ,announced ,in ,a ,waiting ,room.
b. ,There ,is ,no ,violation ,of ,HIPAA ,in ,announcing ,a ,patient's ,name, ,but ,the ,committee
,may ,want ,to ,consider ,implementing ,practices ,that ,might ,reduce ,this ,practice.
c. ,HIPAA ,allows ,only ,the ,use ,of ,the ,patient's ,first ,name.
d. ,HIPAA ,requires ,that ,patients ,be ,given ,numbers ,and ,that ,only ,the ,number ,be
,announced. ,- ,CORRECT ,ANSWER-The ,HIPAA ,Privacy ,Rule ,allows ,communications
,to ,occur ,for ,treatment ,purposes. ,The ,preamble ,repeatedly ,states ,the ,intent ,of ,the
,rule ,is ,not ,to ,interfere ,with ,customary ,and ,necessary ,communications ,in ,the
,healthcare ,of ,the ,individual. ,Calling ,out ,a ,patient's ,name ,in ,a ,waiting ,room, ,or ,even
,on ,the ,facility's ,paging ,system, ,is ,considered ,an ,incidental ,disclosure ,and, ,therefore,
,allowed ,in ,the ,Privacy ,Rule ,(Thomason ,2013, ,37).
