CPMA UPDATED CORE EXAMINATION ALL
QUESTIONS AND ANSWERS SURE A+
✔✔What is the civil monetary penalty for covered entities that fail to comply and
cooperate with any investigation initiated by OCR? - ✔✔Between $100-$50,000 or more
per violation with a calendar year cap of $1,500,000
✔✔When will a covered entity not receive a civil monetary penalty for failing to comply
and cooperate with an investigation initiated by OCR? - ✔✔If the failure to comply was
not due to willful neglect and was corrected within 30 days of identification that the error
occurred; or, if a criminal penalty was imposed by the Department of Justice
✔✔When can penalties be reduced at the discretion of the OCR? - ✔✔If the failure to
comply was due to reasonable cause and the penalty would be excessive based on the
nature and extent of the noncompliance
✔✔What organization is responsible for criminal prosecutions under the Privacy Rule? -
✔✔The Department of Justice
✔✔When are criminal penalties imposed for individuals who have violated the Privacy
Rule? - ✔✔When a person knowingly obtains or discloses individually identifiable health
information in a way that violates the Privacy Rule; penalties may be as much as
,$250,000 and up to 10 years imprisonment if the conduct involves the intent to sell,
transfer, or use identifiable health information for commercial advantage, personal gain,
or malicious harm
✔✔How are medical records requirements generally enforced? - ✔✔Through licensing,
the certification process, or credentialing with insurance carriers
✔✔What components are commonly found in all medical records? - ✔✔A personal
identification number specific to every individual patient; a patient's medical history;
often a medical directive
✔✔Purpose of the personal identification number assigned to each medical record? -
✔✔To ensure accuracy of the details contained within the record and it adds a layer of
security to prevent unauthorized use
✔✔Types of history often involved in the medical record - ✔✔Surgical history, obstetric
history, medications and allergies, family history, social history, immunization history,
developmental history
✔✔Purposed of including a patient's medical history in the record - ✔✔So healthcare
providers can make assessments about a past, current, or future state of an illness
✔✔Purpose of a medical directive - ✔✔To allow the patient to communicate his/her
wishes to the healthcare community prior to any event in which he/she may become
incapacitated to speak, or to make his/her wishes known in certain medical
emergencies
✔✔When are acronyms acceptable in the medical record? - ✔✔When they are
commonly recognized
✔✔What must a practice do if they use abbreviations that are not industry standard? -
✔✔They must maintain a list of the abbreviations with definitions and how they are
used, and should understand that documentation should be submitted anytime an audit
is done.
✔✔What organization has published a standard for the appropriate use of abbreviations
as well as a "minimum list" of dangerous abbreviations, acronyms, and symbols? -
✔✔The Joint Commission (JC)
✔✔What is the purpose of "best practice" standards relating to the contents of a medical
record provided by allied health professional organizations? - ✔✔They are a tool to help
guide health information managers, to ensure accurate and compliant medical records
,✔✔Why are templates often adopted for medical records? - ✔✔To ensure consistency
and accuracy
✔✔What permits providers and suppliers "accredited" by an approved national
accreditation organization (AO) to be exempt from routine surveys by state survey
agencies to determine compliance with Medicare conditions? - ✔✔The Social Security
Act
✔✔Is accreditation by an AO mandatory? - ✔✔No, it is voluntary
✔✔Where can you find a list of AOs online? - ✔✔the Medicare website for accreditation
✔✔What organization is one of the most commonly known accrediting organizations? -
✔✔the JC
✔✔Who established National Safety Goals? - ✔✔the JC
✔✔When were National Safety Goals established? - ✔✔2002
✔✔What is the purpose of National Safety Goals? - ✔✔To help institutions identify
areas where safety can be improved through medication safety and hospital acquired
infections
✔✔What medical record requirements must be in place to be accredited by the
Department of Health and Human Services for Medicare and the JC? - ✔✔Admission
report, consent to treatment form, attestation statement, medical history, physician's
orders, report of physical examination, progress notes, pathology reports, radiology
reports, consultation reports, anesthesia record, operative report, nurse's notes, vital
signs graphics, medication sheet, laboratory report, physical therapy evaluation,
respiratory therapy evaluation, special reports (obstetrics, nursery), and discharge
reports
✔✔What recordkeeping principles apply when a modification is made to the medical
record? - ✔✔Clearly and permanently identify any amendments, corrections, or
addenda; clearly indicate the date and author of any amendments, corrections, or
addenda; and clearly identify all original content (do not delete)
✔✔How should a paper medical record be corrected? - ✔✔A single line strike through
should be used so the original content is still readable; the person altering the medical
record must sign and date the revision, amendment, or addenda
✔✔How should an electronic health record (EHR) be corrected? - ✔✔The amendment,
correction, or delayed entry must be distinctly identified; there must be a way to provide
a reliable means to clearly identify the original content and the modified content; the
, person altering the record and the date of the revision, amendment, or addenda must
be documented
✔✔For how long does HIPAA require privacy records to be maintained? - ✔✔6 years of
the date of its creation, or the date from which it was last in effect (whichever is later)
✔✔Who generally governs medical record retention times? - ✔✔Individual states
✔✔For how long does CMS require hospitals to retain all patient records? - ✔✔At least
5 yrs after the submission of their closed cost reports
✔✔For how long must providers who accept the Medicare Managed Care program
maintain medical records? - ✔✔10 years
✔✔When do state laws regarding medical records retention pre-empt the federal
regulations? - ✔✔When the state laws require longer record retention
✔✔What is the most important component of medical records retention? - ✔✔That the
record is protected, to ensure the security and integrity of the records; they should be
accurately written, promptly completed, filed, and readily accessible
✔✔When should information be entered in the patient's chart? - ✔✔At the time of
service or immediately following the service
✔✔In what circumstances is the importance of timely medical records entries more
critical? - ✔✔When the patient is undergoing a complicated set of services by different
healthcare providers
✔✔Forms of medical record documentation - ✔✔Handwritten, dictated, templates, or
electronic
✔✔Risk areas of handwritten records - ✔✔They are often illegible and abbreviated,
some information may be left off the medical record to reduce the amount of time it
takes to write the note
✔✔Risk areas of dictations - ✔✔It may take several days for the transcriptionist to
transcribe the recorded information and return it to the physician,
✔✔When should corrections be made to dictations? - ✔✔Before it becomes part of the
record
✔✔How much information should be included in a written summary of the services
rendered on the DOS? - ✔✔Enough information about the patient encounter so that it
could be used in place of the transcription in case of loss, misfiling, or inaccuracies
QUESTIONS AND ANSWERS SURE A+
✔✔What is the civil monetary penalty for covered entities that fail to comply and
cooperate with any investigation initiated by OCR? - ✔✔Between $100-$50,000 or more
per violation with a calendar year cap of $1,500,000
✔✔When will a covered entity not receive a civil monetary penalty for failing to comply
and cooperate with an investigation initiated by OCR? - ✔✔If the failure to comply was
not due to willful neglect and was corrected within 30 days of identification that the error
occurred; or, if a criminal penalty was imposed by the Department of Justice
✔✔When can penalties be reduced at the discretion of the OCR? - ✔✔If the failure to
comply was due to reasonable cause and the penalty would be excessive based on the
nature and extent of the noncompliance
✔✔What organization is responsible for criminal prosecutions under the Privacy Rule? -
✔✔The Department of Justice
✔✔When are criminal penalties imposed for individuals who have violated the Privacy
Rule? - ✔✔When a person knowingly obtains or discloses individually identifiable health
information in a way that violates the Privacy Rule; penalties may be as much as
,$250,000 and up to 10 years imprisonment if the conduct involves the intent to sell,
transfer, or use identifiable health information for commercial advantage, personal gain,
or malicious harm
✔✔How are medical records requirements generally enforced? - ✔✔Through licensing,
the certification process, or credentialing with insurance carriers
✔✔What components are commonly found in all medical records? - ✔✔A personal
identification number specific to every individual patient; a patient's medical history;
often a medical directive
✔✔Purpose of the personal identification number assigned to each medical record? -
✔✔To ensure accuracy of the details contained within the record and it adds a layer of
security to prevent unauthorized use
✔✔Types of history often involved in the medical record - ✔✔Surgical history, obstetric
history, medications and allergies, family history, social history, immunization history,
developmental history
✔✔Purposed of including a patient's medical history in the record - ✔✔So healthcare
providers can make assessments about a past, current, or future state of an illness
✔✔Purpose of a medical directive - ✔✔To allow the patient to communicate his/her
wishes to the healthcare community prior to any event in which he/she may become
incapacitated to speak, or to make his/her wishes known in certain medical
emergencies
✔✔When are acronyms acceptable in the medical record? - ✔✔When they are
commonly recognized
✔✔What must a practice do if they use abbreviations that are not industry standard? -
✔✔They must maintain a list of the abbreviations with definitions and how they are
used, and should understand that documentation should be submitted anytime an audit
is done.
✔✔What organization has published a standard for the appropriate use of abbreviations
as well as a "minimum list" of dangerous abbreviations, acronyms, and symbols? -
✔✔The Joint Commission (JC)
✔✔What is the purpose of "best practice" standards relating to the contents of a medical
record provided by allied health professional organizations? - ✔✔They are a tool to help
guide health information managers, to ensure accurate and compliant medical records
,✔✔Why are templates often adopted for medical records? - ✔✔To ensure consistency
and accuracy
✔✔What permits providers and suppliers "accredited" by an approved national
accreditation organization (AO) to be exempt from routine surveys by state survey
agencies to determine compliance with Medicare conditions? - ✔✔The Social Security
Act
✔✔Is accreditation by an AO mandatory? - ✔✔No, it is voluntary
✔✔Where can you find a list of AOs online? - ✔✔the Medicare website for accreditation
✔✔What organization is one of the most commonly known accrediting organizations? -
✔✔the JC
✔✔Who established National Safety Goals? - ✔✔the JC
✔✔When were National Safety Goals established? - ✔✔2002
✔✔What is the purpose of National Safety Goals? - ✔✔To help institutions identify
areas where safety can be improved through medication safety and hospital acquired
infections
✔✔What medical record requirements must be in place to be accredited by the
Department of Health and Human Services for Medicare and the JC? - ✔✔Admission
report, consent to treatment form, attestation statement, medical history, physician's
orders, report of physical examination, progress notes, pathology reports, radiology
reports, consultation reports, anesthesia record, operative report, nurse's notes, vital
signs graphics, medication sheet, laboratory report, physical therapy evaluation,
respiratory therapy evaluation, special reports (obstetrics, nursery), and discharge
reports
✔✔What recordkeeping principles apply when a modification is made to the medical
record? - ✔✔Clearly and permanently identify any amendments, corrections, or
addenda; clearly indicate the date and author of any amendments, corrections, or
addenda; and clearly identify all original content (do not delete)
✔✔How should a paper medical record be corrected? - ✔✔A single line strike through
should be used so the original content is still readable; the person altering the medical
record must sign and date the revision, amendment, or addenda
✔✔How should an electronic health record (EHR) be corrected? - ✔✔The amendment,
correction, or delayed entry must be distinctly identified; there must be a way to provide
a reliable means to clearly identify the original content and the modified content; the
, person altering the record and the date of the revision, amendment, or addenda must
be documented
✔✔For how long does HIPAA require privacy records to be maintained? - ✔✔6 years of
the date of its creation, or the date from which it was last in effect (whichever is later)
✔✔Who generally governs medical record retention times? - ✔✔Individual states
✔✔For how long does CMS require hospitals to retain all patient records? - ✔✔At least
5 yrs after the submission of their closed cost reports
✔✔For how long must providers who accept the Medicare Managed Care program
maintain medical records? - ✔✔10 years
✔✔When do state laws regarding medical records retention pre-empt the federal
regulations? - ✔✔When the state laws require longer record retention
✔✔What is the most important component of medical records retention? - ✔✔That the
record is protected, to ensure the security and integrity of the records; they should be
accurately written, promptly completed, filed, and readily accessible
✔✔When should information be entered in the patient's chart? - ✔✔At the time of
service or immediately following the service
✔✔In what circumstances is the importance of timely medical records entries more
critical? - ✔✔When the patient is undergoing a complicated set of services by different
healthcare providers
✔✔Forms of medical record documentation - ✔✔Handwritten, dictated, templates, or
electronic
✔✔Risk areas of handwritten records - ✔✔They are often illegible and abbreviated,
some information may be left off the medical record to reduce the amount of time it
takes to write the note
✔✔Risk areas of dictations - ✔✔It may take several days for the transcriptionist to
transcribe the recorded information and return it to the physician,
✔✔When should corrections be made to dictations? - ✔✔Before it becomes part of the
record
✔✔How much information should be included in a written summary of the services
rendered on the DOS? - ✔✔Enough information about the patient encounter so that it
could be used in place of the transcription in case of loss, misfiling, or inaccuracies
