Questions and CORRECT Answers
What is one of the main purposes of a medical record? - CORRECT ANSWER - To
provide documentation regarding diagnosis, treatment, and care.
Which tool is most often used to gather a complete medical record? - CORRECT
ANSWER - The Master Patient Index (MPI)
How does the medical record protect legal rights? - CORRECT ANSWER - By
documenting all care decisions and interactions for future reference.
Master Patient Index (MPI) - CORRECT ANSWER - Ensures that patients are accurately
identified across the entire healthcare system, reducing errors.
History & Physical (H&P) - CORRECT ANSWER - Outlines the patient's medical
background and their presenting condition, helping guide diagnosis and treatment.
EKGs and EEGs - CORRECT ANSWER - Assess heart and brain function
Operative and pathology reports - CORRECT ANSWER - Provide critical insights into
surgical procedures and diagnostic findings
Discharge Summary - CORRECT ANSWER - Outlines a patient's diagnosis, treatment,
and follow-up care after discharge
What is the purpose of the Master Patient Index? - CORRECT ANSWER - To link patient
records across healthcare departments.
Who owns the medical record? - CORRECT ANSWER - The healthcare facility.
, Which is considered a breach of confidentiality? - CORRECT ANSWER - Accidentally
releasing the wrong patient's records.
What is the correct action if you suspect a confidentiality breach? - CORRECT
ANSWER - Report it immediately.
The Health Insurance Portability and Accountability Act (HIPAA) - CORRECT
ANSWER - Establishes rules for protecting patient health information (PHI)
HIPAA allows disclosures for Treatment, Payment, and Healthcare Operations (TPO) without
the patient's consent - CORRECT ANSWER - True
What does PHI stand for? - CORRECT ANSWER - Protected Health Information.
Which is NOT required for a HIPAA-compliant authorization? - CORRECT ANSWER -
Fees associated with the disclosure.
Patients have the right to: - CORRECT ANSWER - Access Their Records: Healthcare
providers must honor requests for records in a format the patient prefers (if reasonably
producible).
Request Amendments: Patients may request corrections or updates to inaccurate information.
Restrict Disclosure: If a patient pays for services entirely out-of-pocket, they may request that
those details be withheld from their insurer.
What is an Accounting of Disclosures (AOD) - CORRECT ANSWER - A log that tracks
PHI disclosures.
Can patients access their medical records in electronic form? - CORRECT ANSWER -
Yes, if the information is readily producible.