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⫸ The tool most often used to gather a complete medical record is the: A. Conditions of Admission B. Notice of Privacy Practices C. Master Patient Index D. Information Management Plan Answer: C. Master Patient Index ⫸ The Purpose(s) of the medical record is/are: 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 evaluate care given to the patient D. All of the above Answer: D. All of the above ⫸ Which of the following 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 Answer: D. All of the above ⫸ Which of the following is not required on a HIPAA compliant authorization? A. Name or class of the healthcare provider who is disclosing records B. Information to be disclosed C. Fees associated with the disclosure D. Expiration date of even Answer: C. Fees associated with the disclosure ⫸ A patient presents to the HIM Department requesting information about a recent biopsy. The patient says he wants to know details about the procedure and specifics regarding the specimen removed. The patient should be advised to request a copy of the: A. Entire record B. Operative and Pathology Report C. History and Physical D. None of the above Answer: B. Operative and Pathology Report
⫸ Which of the following does not have access to a patient's health information without authorization? A. Nursing Unit- patient was readmitted to facility B. Medical Staff Physician not treating the patient or consulting - she reviews because patient is a former patient C. Quality Management Employee - reviews for performance improvement data D. Risk Management - reviews for a threatened lawsuit Answer: B. Medical Staff Physician not treating the patient or consulting - she reviews because patient is a former patient ⫸ The PRO or QIO (Peer Review Organization or Quality Improvement Organization) who is contracted with CMS (Centers for Medicare & Medicaid Services) requests copies of medical records. Are they allowed to receive copies without an authorization for a patient with schizophrenia (mental health condition?) A. Yes B. No Answer: A. Yes ⫸ What is the difference between a request and a patient's authorization? A. There is no difference
B. The request is verbal and the authorization is in writing C. The request is in writing and asks that records be disclosed; the authorization is the patient's written permission to do so Answer: C. The request is in writing and asks that records be disclosed; the authorization is the patient's written permission to do so ⫸ If there is a breach of health information, which of the following enforcement legal actions may be taken: A. Civil Action B. Criminal Action C. Both D. Neither Civil or Criminal Action Answer: C. Both ⫸ Birth and death certificates may be disclosed by a hospital. A. True B. False Answer: B. False ⫸ What records should you disclose in response to a Medicare request for records? A. Records specified for dates requested B. The entire record
B. To bring identification with her when she comes to pick up the records C. That Bet Answer: D. Both B and C ⫸ A woman calls to tell you she has received a bill for outpatient services (she has already spoken to the billing department), but was never a patient at the facility. She suspects someone has fraudulently used her name and insurance information. She requests a copy of the record "out of curiosity." You should tell her: A. You will speak to the appropriate manager about correcting the situation so that the record does not appear under her name, but you cannot release health information related to another person without consent of the patient B. She is entitled to the information since the person used her name C. You cannot give it to her since you know the situation, but if she calls back and speaks to the HIM Director, she can probably get the information Answer: A. You will speak to the appropriate manager about correcting the situation so that the record does not appear under her name, but you cannot release health information related to another person without consent of the patient ⫸ A man calls and says that he wants his History & Physical sent to an insurance company because he is applying for life insurnance. He states, "One minor thing- if it has anything in there about my history of smoking, please redact that information." You tell him:
A. You must copy the report in full, as it appears in the record. You apologize that you cannot fulfill his special request, but this would be considered tampering with his medical record B. You can fold the report when you copy it so it will not appear on the copy C. You tell him to have the records sent to him so he can make any changes he wants and then send it off to the insurance company Answer: A. You must copy the report in full, as it appears in the record. You apologize that you cannot fulfill his special request, but this would be considered tampering with his medical record ⫸ A patient signs an authorization for disclosure of medical record and you notice the patient was treated in the chemical dependency program. The authorization you received is a general authorization. You should: A. Call to tell the patient that it is a special circumstance and ask whether you should still send the records B. Sent the records but mark them with a special stamp C. Send a letter requesting special authorization for this particular situation, and enclose the special authorization that's required D. Send the records as requested Answer: C. Send a letter requesting special authorization for this particular situation, and enclose the special authorization that's required ⫸ A nurse who works at your facility comes into the HIM department to request copies of the medical record of her mother-in-law, who now resides in a local nursing home. The nurse tells you she has power of attorney and needs the records for personal reasons
⫸ You are working in a children's hospital. You have received a request from the mother of a 17-year-old married patient for his medical records. The parents consented for the 17-year-old to marry and marriage is grounds for emancipation in the state. The mother requests her son's records to complete the personal health record she has compiled and wishes to give to her son. You should: A. Deny the request because the age of majority in the state is 18 B. Tell the mom the son must sign the authorization since he is an emancipated minor C. Tell the mom her son's wife must sign the authorization now that she is the next of kin D. Process the request since the mother is listed as next-of-kin in the record Answer: B. Tell the mom the son must sign the authorization since he is an emancipated minor ⫸ A man walks into the Health Information Management Department where you work. He is asking for copies of his now deceased father's records. You should: A. Produce the requested records and bill him for the pages B. Tell the son you need authorization form the father's spouse C. Refuse the request because the EHR does not confirm that the patient is truly deceased D. Ask for a copy of court documents appointing him executor or administrator of the father's estate. If there is no executor or
administrator, ask for a copy of the death certificate and determine who is "next of kin" or has access to a deceased patient's records in your state before you prepare the records for disclosure Answer: D. Ask for a copy of court documents appointing him executor or administrator of the father's estate. If there is no executor or administrator, ask for a copy of the death certificate and determine who is "next of kin" or has access to a deceased patient's records in your state before you prepare the records for disclosure ⫸ An insurance company is requesting the medical records of aperson who wants to purchase life insurance. The authorization submitted is invalid. But the agent has called you three times about this request and is begging you to copy the records. You should: A. Reproduce the records while he tries to get a new authorization from the patient B. Tell the agent you need a valid authorization before you can reproduce the records C. Call the patient and ask if it is okay for you to copy his health records for the agent D. copy the records and mail the records to the home office of the insurance company instead of giving them directly to the agent Answer: B. Tell the agent you need a valid authorization before you can reproduce the records ⫸ You are working in a clinic filling in for a vacation employee, who is the only employee at this location. A request and valid authorization for the medical records of your neighbor is in the stack of requests you have to process today. You should:
A. True B. False Answer: A. True ⫸ A doctor requests copies of his wife's records whom he is not treating and she has no medical condition that would limit her ability to consent. You must deny the request for copies of the record because you don't have a signed authorization from the wife. A. True B. False Answer: A. True ⫸ A minor's mother calls your HIM Department explaining that her family moved and the school needs a copy of her child's immunization records to begin school the next day. She states that she can fax a letter with full instructions. Immunization records are required for a child to begin school in both the old and the new state where the minor resides. What should you do? A. Ask the mother to fax her request with the minor's full name, identification data & recipient instructions so that you may process the request right away. B. Tell the mother an authorization is required per HIPAA and her written request is not good enough Answer: A. Ask the mother to fax her request with the minor's full name, identification data & recipient instructions so that you may process the request right away.
⫸ One of the HIM employees brings a chart to you and asks you to copy some of the records. This employee does not have a patient authorization. What should you do? A. Tell the employee that you need a HIPAA compliant authorization singed by the patient to disclose records to her before you can copy the record B. Copy the record, because she wouldn't have asked you to copy something if she didn't need it C. Tell the HIM manager the employee is doing something unethical D. Put it on your desk and "forget" to do it Answer: A. Tell the employee that you need a HIPAA compliant authorization singed by the patient to disclose records to her before you can copy the record ⫸ You have access to the computer at your facility. You forgot your password, but the computer next to your desk is on and no one is working there. Should you use that computer? A. Yes. The computer has the same programs, so it is okay for you to sue this computer B. No. You should call the person in charge of passwords at your facility, and ask for help Answer: B. No. You should call the person in charge of passwords at your facility, and ask for help ⫸ A revocation of an authorization allows the patient to change his/her mind about the release of their medical records if it has not been acted upon yet.
⫸ HIPAA's Privacy Rule gives a patient the right to access their: A. Medical record only B. Designated Record Set C. Itemized bill only D. Insurance records only Answer: B. Designated Record Set ⫸ Can a healthcare facility deny a patient's request to amend or correct his/her medical record? A. Yes B. No Answer: A. Yes ⫸ What are required disclosures under the HIPAA Privacy Rule? A. Disclosures to the patient B. Disclosures to another healthcare facility C. Disclosures to the Secretary of HHS for purposes of compliance D. Both A and C Answer: D. Both A and C ⫸ Which of the following is not a public priority exception to HIPAA's Privacy Rule? A. Child or elder abuse investigation B. Public health reporting C. Insurance company claim payment
D. Coroner or medical examiner investigation Answer: C. Insurance company claim payment ⫸ For which reason under HIPAA's Privacy Rule can protected health information be disclosed without authorization? A. Treatment B. Payment C. Healthcare operations D. All of the above Answer: D. All of the above ⫸ Under HIPAA, a personal representative is an individual who can sign an authorization to disclose PHI on behalf of a patient. Choose all possible personal representatives: A. Patient's attorney B. Legal guardian of a minor child C. Primary caregiver D. A and B Answer: B. Legal guardian of a minor child ⫸ A person who requests and authorizes the designated record set for a deceased patient as a personal representative must provide proof that he/she is the executor of the estate, administrator of the will or other person with the authority bestowed by the state law to act on behalf of the deceased patient of the estate. A. True B. False Answer: A. True
B. False Answer: A. True ⫸ Incidental disclosures are permitted; however, the covered entity must use reasonable and appropriate safeguards. A. True B. False Answer: A. True ⫸ Covered entities are permitted to re-disclose patient health information received from other healthcare providers for treatment purposes per HIPAA. A. True B. False Answer: A. True ⫸ A person or organization that performs a function or activity on behalf of a covered entity, but is not a part of the covered entity's workforce is called: A. A HIPAA Contingent B. A Business Associate C. A Patient's Advocate D. All of the above Answer: B. A Business Associate ⫸ The HIPAA Privacy Rule generally treats information about one medical condition the same as information about any other medical condition. Psychotherapy Notes are an exception. Psychotherapy notes may not be routinely shared and require patient authorization for any disclosure.
A. True B. False Answer: A. True ⫸ What does HIPAA stand for? A. Health Information Privacy and Accountability Act B. Health Information Protection and Authorization Act C. Health Insurance Portability and Accountability Act D. Health Information Portability and Accountability Act Answer: C. Health Insurance Portability and Accountability Act ⫸ What does PHI stand for? A. Public Health Information B. Protected Health Information C. Patient Health Information D. None of the above Answer: B. Protected Health Information ⫸ What is/are personal identifier/s that become PHI if combined with health or payment information? A. Vehicle license plate number B. Mobile phone number C. A and B D. None of the above Answer: C. A and B
