, CRIS TEST A
1. A patient is receiving ongoing care at a health care facility, and several members
of the health care team are documenting information about the patient’s
condition, treatments, medications, and progress. The patient asks who legally
owns the medical record that is created and maintained during the course of care.
Which party is generally considered the owner of the medical record?
A. The patient
B. The physician
C. The health care facility
D. The federal government under HIPAA
Correct Answer: C. The health care facility
The health care facility generally owns the physical medical record because it is
responsible for creating, maintaining, securing, and storing the record. Although the
patient does not own the physical record, the patient has important rights to access
and obtain copies of the information contained within it. HIPAA establishes privacy
and access requirements but does not make the federal government the owner of
the medical record. The physician may contribute documentation to the record, but
ownership generally remains with the facility that maintains it.
2. A health care facility needs to accurately identify patients and organize their
records so that information can be located and maintained as part of the patient’s
medical history. Health information staff use a systematic tool to help identify
patients and link them with their records across the health care system. Which tool
is most often used to gather and organize information needed for a complete
medical record?
A. Conditions of Admission
B. Notice of Privacy Practices
,C. Master Patient Index
D. Information Management Plan
Correct Answer: C. Master Patient Index
The Master Patient Index (MPI) is a key health information management tool used to
identify patients and link them with their medical records within a health care
organization. It contains identifying information that helps prevent duplicate records
and ensures that documentation is associated with the correct patient. The
Conditions of Admission and Notice of Privacy Practices provide important
administrative and legal information but are not designed to identify and organize
patients’ records. The Information Management Plan establishes broader policies and
procedures for managing health information rather than serving as the primary
patient-identification index.
3. A health care organization maintains a medical record containing information
about a patient’s diagnosis, treatment, and outcomes. The record may be used by
health care professionals, legal representatives, educators, and researchers for
several legitimate purposes related to patient care and health information
management. Which of the following best describes the purposes of the medical
record?
A. To assist in further research and education
B. To assist in protecting the legal rights of the patient and the healthcare facility
C. To provide analysis, study, and evaluation of care given to the patient
D. All of the above
Correct Answer: D. All of the above
The medical record serves multiple purposes, including supporting patient care,
research, education, quality improvement, and evaluation of health care services. It
also provides documentation that can help protect the legal rights of both the patient
and the health care facility. Health care organizations can analyze medical records to
, study outcomes and evaluate whether appropriate care was provided. Therefore, all
of the listed purposes accurately describe legitimate functions of the medical record.
4. A health information management department receives several requests for
protected health information from outside parties. During the review process, staff
identify situations in which information may be disclosed without proper
authorization or may be sent to the wrong individual. Which of the following
situations may be considered an improper disclosure of protected health
information?
A. Releasing records to a requester for legal purposes without a signed patient
authorization
B. Accidentally releasing the wrong patient's records to a requester
C. Releasing dates of service to a requester if the treatment dates are not authorized
D. All of the above
Correct Answer: D. All of the above
Each listed situation can potentially constitute an improper disclosure of protected
health information when the disclosure does not meet an applicable HIPAA
permission or exception. Releasing records without the required authorization,
sending the wrong patient's information, or disclosing information beyond the scope
of an authorization can compromise patient privacy. Health care organizations must
verify the identity of the requester, the legal basis for disclosure, and the scope of
information that may be released. Therefore, all of the listed circumstances may
represent improper disclosures depending on the applicable legal requirements.
5. A patient completes an authorization allowing a health care provider to disclose
specified protected health information to another party. The health information
management department reviews the authorization to ensure that it contains the
required elements for a valid HIPAA authorization. Which of the following is not
required to be included on a HIPAA-compliant authorization?
1. A patient is receiving ongoing care at a health care facility, and several members
of the health care team are documenting information about the patient’s
condition, treatments, medications, and progress. The patient asks who legally
owns the medical record that is created and maintained during the course of care.
Which party is generally considered the owner of the medical record?
A. The patient
B. The physician
C. The health care facility
D. The federal government under HIPAA
Correct Answer: C. The health care facility
The health care facility generally owns the physical medical record because it is
responsible for creating, maintaining, securing, and storing the record. Although the
patient does not own the physical record, the patient has important rights to access
and obtain copies of the information contained within it. HIPAA establishes privacy
and access requirements but does not make the federal government the owner of
the medical record. The physician may contribute documentation to the record, but
ownership generally remains with the facility that maintains it.
2. A health care facility needs to accurately identify patients and organize their
records so that information can be located and maintained as part of the patient’s
medical history. Health information staff use a systematic tool to help identify
patients and link them with their records across the health care system. Which tool
is most often used to gather and organize information needed for a complete
medical record?
A. Conditions of Admission
B. Notice of Privacy Practices
,C. Master Patient Index
D. Information Management Plan
Correct Answer: C. Master Patient Index
The Master Patient Index (MPI) is a key health information management tool used to
identify patients and link them with their medical records within a health care
organization. It contains identifying information that helps prevent duplicate records
and ensures that documentation is associated with the correct patient. The
Conditions of Admission and Notice of Privacy Practices provide important
administrative and legal information but are not designed to identify and organize
patients’ records. The Information Management Plan establishes broader policies and
procedures for managing health information rather than serving as the primary
patient-identification index.
3. A health care organization maintains a medical record containing information
about a patient’s diagnosis, treatment, and outcomes. The record may be used by
health care professionals, legal representatives, educators, and researchers for
several legitimate purposes related to patient care and health information
management. Which of the following best describes the purposes of the medical
record?
A. To assist in further research and education
B. To assist in protecting the legal rights of the patient and the healthcare facility
C. To provide analysis, study, and evaluation of care given to the patient
D. All of the above
Correct Answer: D. All of the above
The medical record serves multiple purposes, including supporting patient care,
research, education, quality improvement, and evaluation of health care services. It
also provides documentation that can help protect the legal rights of both the patient
and the health care facility. Health care organizations can analyze medical records to
, study outcomes and evaluate whether appropriate care was provided. Therefore, all
of the listed purposes accurately describe legitimate functions of the medical record.
4. A health information management department receives several requests for
protected health information from outside parties. During the review process, staff
identify situations in which information may be disclosed without proper
authorization or may be sent to the wrong individual. Which of the following
situations may be considered an improper disclosure of protected health
information?
A. Releasing records to a requester for legal purposes without a signed patient
authorization
B. Accidentally releasing the wrong patient's records to a requester
C. Releasing dates of service to a requester if the treatment dates are not authorized
D. All of the above
Correct Answer: D. All of the above
Each listed situation can potentially constitute an improper disclosure of protected
health information when the disclosure does not meet an applicable HIPAA
permission or exception. Releasing records without the required authorization,
sending the wrong patient's information, or disclosing information beyond the scope
of an authorization can compromise patient privacy. Health care organizations must
verify the identity of the requester, the legal basis for disclosure, and the scope of
information that may be released. Therefore, all of the listed circumstances may
represent improper disclosures depending on the applicable legal requirements.
5. A patient completes an authorization allowing a health care provider to disclose
specified protected health information to another party. The health information
management department reviews the authorization to ensure that it contains the
required elements for a valid HIPAA authorization. Which of the following is not
required to be included on a HIPAA-compliant authorization?
