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1. Purposes of medical record - ANSWER ✔ 1. To provide a communication
tool between all healthcare providers. A physician, nurse, and any healthcare
professional that treats the patient will complete documentation within the
medical records
To provide documentation regarding diagnosis, treatment, and care of the
patient while to find a receiving services from a healthcare facility.
To provide information needed for medical billing of services rendered to
the patient and hospital financial management.
To provide a medium for analysis, study, and evaluation of the quality of
care given to a patient.
To assist in protecting the legal rights of the patients, the healthcare facility,
and other healthcare providers.
2. A master patient index (MPI) - ANSWER ✔ Tool gathered to obtain the
complete medical record. (Is electronic medical database that holds
information on every patient registered at a healthcare organization.)
3. Discharge summary - ANSWER ✔ Summary of treatment the patient
received. Includes the diagnosis of their ailment. This is usually a
transcribed report.
,4. history and physical - ANSWER ✔ Reflects the history of the patients
disease or injury, as well as the history of treatment. Usually transcribed, but
may be hand written at the beginning of the progress notes.
5. Can a patient designate third-party to receive a copy of the protected health
information if the request is in writing, clearly identifies a third-party
recipient and where to send the copies - ANSWER ✔ Yes
6. Can a facility deny access to a patient when it is determined that access
would be harmful to the patients health - ANSWER ✔ Yes
7. A patient may receive an accounting of disclosures for records in paper
format up to - ANSWER ✔ 6 years
8. Accounting if disclosures - ANSWER ✔ Is a summary of information
released, the date the information was released, whose information it was
released to and the purpose for releasing information. AOD does not need to
include disclosures pursuant to the authorization
9. A covered entity can deny the request to amend the medical record if -
ANSWER ✔ It is found that the document was not created by the covered
entity, the document is not part of the designated record set, if the document
would not be available for patient access if it was deemed accurate and
complete
10.The omnibus rule added the requirement that - ANSWER ✔ Facilities must
restrict information from being disclosed to a patient's health insurance
payer if the patient pays for the service in full and requests such restriction
,11.Business associate - ANSWER ✔ A person or organization that perform a
function or activity on behalf of a covered entity, but is not part of the
covered entities work force. A business associate must comply with HIPPA
privacy and security rules and is liable and subject to fines for non
compliance
12.The notice of privacy practices must include a - ANSWER ✔ Description of
the type of uses and disclosures that require patient authorization, must be
displayed or posted on a healthcare facilities website and must be signed by
patients upon the first visit to a physician
13.Protected health information PHI - ANSWER ✔ Individually identifiable
health information. Example: names, addresses, ZIP Code, admission and
discharge dates, birthdate, telephone and fax numbers, email addresses,
Social Security number, medical record number, health plan numbers,
account number, finger or voice prints, fullface photograph
14.Who owns the medical record?
A. The patient
B. The physician
C. The health care facility
D. The federal government under HIPAA - ANSWER ✔ C. The health
care facility
15.What does an Insurance Underwriter primarily do?
A. Process applications for life and health insurance
B. Process claims for benefits related to accidental injuries
C. Process claims for benefits related to workers compensation
, D. Process post-payment audits of health information - ANSWER ✔ A.
Process applications for life and health insurance
16.What does an Insurance Adjuster primarily do?
A. Process applications for life and health insurance
B. Process claims for benefits related to accidental injuries
C. Process claims for benefits related to workers compensation
D. Process audits of medical records - ANSWER ✔ B. Process claims for
benefits related to accidental injuries
17.What does a Peer Review or Quality Improvement Organization primarliy
do?
A. Process applications for life and health insurance
B. Process claims for benefits related to accidental injuries
C. Process claims for benefits related to workers compensation
D. Process audits of medical records - ANSWER ✔ D. Process audits of
medical records
18.An accounting of disclosure includes:
A. A summary of the information released
B. The date health information was released
C. Who the information was released to
D. All of the above - ANSWER ✔ D. All of the above
19.If a patient does not agree with something documented in the health record,
he or she can request a correction to the record.