Question 1

In electronic health records, authentication may be achieved by

Accepted Answer

Handwritten signatures can easily be forged or copied, and verbal statements cannot be easily traced or authenticated. Digital signatures, on the other hand, use encryption and certificates to ensure the authenticity and integrity of the record, making them the most secure and reliable option for authentication in electronic health records.

Question 2

What advice should be given to a physician who has just informed you that she just discovered that a significant portion of a discharge summary she dictated last month was left out?

Accepted Answer

The best choice would be for the physician to dictate the omitted portion with a heading of "Discharge Summary-Addendum" and reference it with a note that is dated and signed on the initial Discharge Summary. This ensures that the complete and accurate information is included in the patient's medical record, and also provides a clear indication that an addendum was added at a later date. Squeezing in the information or re-dictating the entire discharge summary may cause confusion or errors. Option D is not a viable solution as it does not address the issue at hand.

Question 3

Which of the following statements is correct regarding HIPAA preemption analysis?

Accepted Answer

HIPAA preemption analysis involves determining whether a state law conflicts with the HIPAA federal rule and if so, which shall prevail. If the state law provides greater protections for a patient's health care information privacy than the HIPAA federal rule, the state law prevails. This is known as the "more stringent" standard. Therefore, statement A is correct. Statements B, C, and D are incorrect.

Question 4

When a record custodian brings the medical record to court in response to a subpoena duces tecum, it is her responsibility to

Accepted Answer

The record custodian's responsibility is to identify the record in her official capacity as custodian. It is not her responsibility to present the case favorably for the patient, explain details of medical treatment or leave the original record in possession of the plaintiff's attorney.

Question 5

When substituting a photocopy of the original record in response to legal process, which of the following can be helpful in convincing the court to accept the photocopy as a true and exact copy of the original?

Accepted Answer

A certificate of authentication can provide evidence that the photocopy is a true and exact copy of the original record. It can be obtained from a notary public, an authorized official, or an agency responsible for maintaining the record. Consent from the patient or hospital administrator, or correspondence from the attending physician, may not necessarily prove the authenticity of the photocopy.

Question 6

The Uniform Business Records as Evidence Act addresses

Accepted Answer

The Uniform Business Records as Evidence Act addresses the admissibility of record reproductions, which allows for copies or duplicates of business records to be admitted into evidence as long as they were made in the regular course of business and are deemed trustworthy. While the other options may involve business records, they are not the primary focus of this act.

Question 7

Which of the following should be required to sign a confidentiality statement before having access to patients' medical information?

Accepted Answer

All of the above should be required to sign a confidentiality statement before having access to patients' medical information. This is to ensure that they understand the importance and legal obligation of maintaining patient confidentiality.

Question 8

The minimum record retention period for patients who are minors is

Accepted Answer

The minimum record retention period for patients who are minors is typically the age of majority plus the statute of limitations, to ensure that records are available for any legal claims that may arise once the patient reaches adulthood.

Question 9

To be admitted into court as evidence, medical records or health information are introduced as

Accepted Answer

Medical records or health information are typically introduced as records or exceptions to the hearsay rule, which allows certain out-of-court statements to be admitted as evidence if they fall under certain specific categories. This includes records kept in the regular course of business, such as medical records, which are presumed to be reliable and accurate. They are not considered torts, contracts, privileged information, or product liability.

Question 10

The ideal consent for medical treatment obtained by the physician is

Accepted Answer

Informed consent is the best choice as it requires the physician to discuss with the patient the nature of the treatment, its risks and benefits, and any possible alternatives before the patient can give consent. This ensures that the patient is fully informed before making a decision about their medical treatment. Express or verbal consent may not provide enough information to the patient while implied consent may not be clear or specific enough for the treatment at hand.

Question 11

While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation?

Accepted Answer

The incident report should be referred to the Risk Manager for further review and appropriate action, which may include removal of the report from the record. The supervisor should follow the appropriate policy and procedure for dealing with incident reports in medical records. The other options, such as removing the report and sending it to the patient, or transferring the documentation to the medical record, may not be appropriate without further review and analysis.

Question 12

Many states have recognized a minor's right to seek treatment without parental consent in all of the following situations EXCEPT a(n)

Accepted Answer

A minor seeking treatment for breast reduction is not typically recognized as a situation where a minor has the right to seek treatment without parental consent.

Question 13

The proper method for correcting a documentation error in a medical record is for the author to

Accepted Answer

Drawing a single line through the incorrect information, dating and initialing the change is the proper method for correcting a documentation error in a medical record. This shows that the error was acknowledged and corrected by the author, and also allows for a trail of documentation in case of any future audits or inquiries. The other choices do not provide a clear indication of the correction made or may be seen as attempting to conceal the error.

Question 14

It is common practice to forgo patient authorization for the release of information when the

Accepted Answer

When a patient has a direct transfer from the hospital to a long-term care facility, the release of information is considered part of the continuity of care and does not require explicit patient authorization. This is because the information is necessary for the patient's ongoing treatment and care. However, in all other cases, patient authorization is required before releasing their health information.

Question 15

Written consent from the patient is required for which of the following in order to learn a patient's HIV status?

Accepted Answer

Insurance companies require written consent from the patient to access their HIV status due to privacy and confidentiality regulations.

Question 16

Which of the following is considered confidential information if the patient is seeking treatment in a substance abuse facility?

Accepted Answer

All of the listed information is considered confidential in the context of a substance abuse facility, as it pertains to the patient's identity and treatment details.

Question 17

A health care organization's compliance plans should not only focus on regulatory compliance, but also have a

Accepted Answer

A compliance plan should include a coding compliance program to prevent fraudulent coding and billing, which is a critical aspect of regulatory compliance in healthcare.

Question 18

All of the following are sources for the rules and regulations that define the legal aspects of medical records EXCEPT

Accepted Answer

Paralegals are not a source for the rules and regulations that define the legal aspects of medical records. The other options, including institutional policies, laws, and governmental and nongovernmental regulations, are all sources for the legal aspects of medical records.

Question 19

All of the following have laws and regulations addressing medical records EXCEPT

Accepted Answer

Corporate law does not typically address medical records unless the corporation is a healthcare provider or covered entity under HIPAA regulations. Accreditting agencies, state laws, and federal laws all have specific requirements for the maintenance and disclosure of medical records.

Question 20

The Privacy Act of 1974 permits patients to request amendments to their medical record in which type of facility?

Accepted Answer

The Privacy Act of 1974 applies to federal agencies, including the Department of Defense, allowing patients to request amendments to their records held by such entities.

Exam 1: Registered Health Information Administrator