Module 2: Information Retention and Access
When operating under the Health Insurance Portability and Accountability Act of 1996, what is a basic tenet in information security for health care professionals to follow? When paper-based records are no longer needed, they are bundled and sent to a recycling center. Patients are not educated about their right to confidentiality of health information. The information system encourages mass copying, printing, and downloading of patient records. Security training is provided to all levels of staff.
Security training is provided to all levels of staff. According to the administrative safeguards, entities must provide security training for all staff.
General Hospital utilizes various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports. What application would be MOST effective for this activity? command interpreter desktop publishing word processing database management system
database management system A database management system provides a better solution for capturing and managing data.
The steps in developing a record retention program include all but which of the following? determining the storage format and location assigning each record a retention period destroying records that are no longer needed notifying the courts of the destruction
notifying the courts of the destruction Notifying the courts is not required for record destruction.
Which one of the following is NOT a data retrieval tool? sound point-and-click fields color icons
point-and-click fields
Which of the following is NOT a document input device in the electronic document management system? scanner bar codes printer touch screen
printer A printer is an output device.
As a prerequisite in the implementation of an electronic health record, what process would facilitate automatic indexing? redesigning forms to include bar codes converting all microfilm to optical disk format removing portions of the patient record that will not be scanned scanning only emergency room records initially
redesigning forms to include bar codes Barcoding is an essential component of the document indexing function.
A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased? 14 13 11 12
14 2,540 + 400 = 2,940 inches needed 36 × 6 = 216 inches per unit 2,940 (inches needed) divided by 216 (inches per unit) = 13.61 shelves You must buy 14 units because you cannot purchase a 13.61 filing shelf.
How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained? 7 permanently 5 30
30 Organizations with special patient populations (such as research patients) have to maintain their records for a longer period of time. The FDA requires research records pertaining to cancer patients to be maintained for 30 years.
What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program? 70% 100% 80% 90%
90% A 90% target rate. This target rate has been established by the Commission on Cancer (CoC) of the American College of Surgeons (ACoS).
Which of the following statements would be found in the laboratory report section of the health record? IV sodium Pentothal 1% started at 9:05 AM BUN reported as 20 mg TPR recorded q.h. for 12 hours Morphine sulfate gr. 1/4 q.4h. for pain
BUN reported as 20 mg The blood urea nitrogen (BUN) test evaluates kidney function. The results of this test would be found on a laboratory report.
When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT needs and wishes of patients. state laws and licensing standards. Medicare requirements. Communities of Practice requirements.
Communities of Practice requirements. It is not necessary to consider Communities of Practice requirements when addressing disposition of patient records.
A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be taken? Destroy inactive records that exceed the statute of limitations. Destroy records of all deceased patients. Maintain the records indefinitely in hard copy. Return inactive records to each individual patient.
Destroy inactive records that exceed the statute of limitations. Before destroying health records, health care facilities must consider regulations, statutes, accreditation standards, organizational policies, pending litigation, storage, and cost.
Which one of the following is NOT an advantage of a computerized master patient index? Duplication of patient registration can never occur. It provides other departments with immediate access to the information maintained in the master patient index. It allows access to data alphabetically, phonetically, or by date of birth, Social Security number, medical record, or billing number. It solves most space and retrieval problems.
Duplication of patient registration can never occur. Duplication of patient health records is a quality issue in the MPI. This is a disadvantage of the MPI.
What data cannot be retrieved from the MEDPAR? Charges broken down by specific types of services ICD-10-CM diagnosis codes Non-Medicare patient data Data on the provider
Non-Medicare patient data The MEDPAR consists of Medicare claims data only.
Which one of the following actions would NOT be included in the professional obligations of the health information practitioner that lead to responsible handling of patient health information? Educate consumers about their rights and responsibilities regarding the use of their personal health information. Honor the patient-centric direction of the national agenda. Extend privacy and security principles into all aspects of the data use, access, and control program adopted in the organization. Take a compromising position toward optimal interpretation of nonspecific regulations and laws.
Take a compromising position toward optimal interpretation of nonspecific regulations and laws. Taking a compromising position regarding interpretation of regulations and laws would be unprofessional and unethical. Per the AHIMA Code of Ethics, AHIMA members should demonstrate ethics and compliance in their professional practice activities.
If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the date of admission. Social Security number. mother's maiden name. date of birth.
date of birth. For confidentiality reasons, the patient's Social Security number should not be used. The names would appear in the MPI in the following order: Brown, Charlotte M. DOB: January 22, 1970 Brown, Charlotte M. DOB: June 12, 1981 Brown, Charlotte M. DOB: December 18, 1981
When engaging the services of a paper record storage vendor, all but which one of the following factors should be included in the contract? climate control policies record retrieval turnaround time name and cell phone number of vendor delivery drivers confidentiality policies
name and cell phone number of vendor delivery drivers The contract should address all aspects of storing, retrieving, and protecting the paper records. Identification and personal contact information of vendor employees should not be part of the contract.
What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital? storing the records off-site at a cost of $25,000 per year purging and storing all death records off-site at a cost of $20,000 per year destroying all records older than 3 years for a cost of $50,000 scanning all 250,000 records for a cost of $195,000
scanning all 250,000 records for a cost of $195,000 Scanning the records would make them easily accessible and would not require storage costs over a long period of time.
As HIM director, you must ensure a means to regulate access and ensure preservation of data in the health care facility's computer system. Which of the following is NOT a security measure that can be implemented to prevent privacy violations in this computer system? stonewall disaster recovery plan authentication encryption
stonewall A stonewall is not a security measure.
Under the HIPAA Privacy Rule, when destruction services are outsourced to a business associate, the contract must provide that the business associate will establish the permitted and required uses and disclosures and include all but which of the following elements? method of destruction or disposal the hospital's liability insurance in specified amounts safeguards against breaches time that will elapse between acquisition and destruction or disposal
the hospital's liability insurance in specified amounts The hospital's liability insurance is not included.
The HIM practitioner's duty to retain health information via the archiving and storage of health data includes all EXCEPT which of the following? strategies that consider accessibility, natural disasters, and innovations in storage technology a retention plan for multiple volumes of records strategies ensuring that inactive records are as secure as active records a retention plan for financial data
a retention plan for financial data The HIM professional would not be responsible for retaining financial data.
The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the laboratory tests that generate a charge, but they cannot see the test results. What kind of control is this an example of? integrity concurrency cost access
access This access safeguard allows employees to only access the data that they need to perform their jobs.
Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long? 10 years after the most recent encounter 10 years after the age of majority age of majority plus statute of limitation permanently
age of majority plus statute of limitation AHIMA has recommended retention standards for various types of health information. For minors, it is recommended that the retention period extend beyond the age of majority (some states is age 18, others 21 years of age). The record retention period recommended for these records is the age of majority plus the statute of limitation mandated for retention of adult records.
What is the chief criterion for determining record inactivity? efficiency of microfilming amount of space available for storage of newer records Medicare's definition of inactivity preference of the medical staff
amount of space available for storage of newer records Records may need to be purged to create space for newer records. When purging records, the HIM professional must consider many factors, such as the facility's readmission rate, available file space, and user access needs.
University Hospital, a 900-bed tertiary health care organization, is undergoing an information systems development. What system would best meet its needs? legacy system IBM Medical Information Systems Program application service provider model clinical workstation
application service provider model With the application service provider model, another entity or business manages the technology, not the health care organization; and the software and servers are located off-site.
Which one of the following is NOT a technical security control employed by electronic health record systems? data encryption protocols audit trails automatic log off user-based access controls
automatic log off Automatic log off after a period of inactivity is an administrative safeguard. Technical safeguards consist of five categories: access controls, audit controls, integrity, person or identity authentication, and transmission security.
A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would be filed in a health record created for the infant. be filed in the mother's record. not be retained in hospital records. be retained in a separate file in the administrative office.
be filed in the mother's record. Stillborns are also called fetal deaths. The documentation on the stillborn is filed in the mother's health record. The stillborn has no health record
The director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. Which of the following would be the key advantage in using this type of data entry? Those physicians not in compliance will be denied admitting privileges. Enhanced databases will provide information for improved clinical care. Training will be offered by the hospital. Multiple users will not have access to the same information simultaneously.
Enhanced databases will provide information for improved clinical care. There are many advantages. When speaking with physicians, the HIM director should stress how enhanced databases can improve the provision of patient care.
The Assistant Director of Record Processing is evaluating software packages for a chart-tracking system in the HIM Department. What is the BEST method to verify that the software will work as marketed? Perform a vendor reference check. Read consumer reports before buying. Test the software prior to purchase. Visit corporate headquarters of the vendor.
Test the software prior to purchase. Testing is the only way to confirm that the software will work as advertised.
A health care facility has received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the newborn records. birth defects registry. maternal records. state bureau of vital statistics.
birth defects registry. Cleft lips and cleft palates are birth defects. This information would be included in a birth defects registry.
When evaluating an outside contract with a paper record storage facility, all but which of the following are important factors to rate? storage after filming cache memory cost emergency returns
cache memory Cache is used to store data on a computer.
The assistant director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they move through the completion process. What departmental function is this most useful for? release of information transcription chart tracking coding
chart tracking With an automated chart-tracking system, the record is "checked out" and assigned to the requestor. The record's location is maintained by the computer.
University Hospital has the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal lab result to the appropriate physician's pager number. Which one of the following is the medical staff using? intranet Internet extranet clinical information system
clinical information system A clinical information system (CIS) maintains health information and makes it available to health care providers.
In negotiating a contract with a commercial storage company for storage of inactive records, what would be the most important issue to clarify in writing? what are the billing terms who completes the list of what records are to be stored who will purge inactive files for transfer confidentiality policies and liability concerns
confidentiality policies and liability concerns The health care facility must adhere to privacy and security regulations while records are in storage.
Which of the following is NOT considered a challenge in the adoption of an electronic health record system? physician willingness to adopt individual state legal and regulatory issues contribution to the quality of patient care design of the work flow and processes
contribution to the quality of patient care The adoption of EHRs has faced many challenges over the years, such as work flow and process design, legal and regulatory issues, and physician adoption.
It is recommended that all but which of the following information should be permanently retained in some format, even when the remainder of the health record is destroyed? discharge summaries nursing notes dates of admission, discharge, and encounters physician names
dates of admission, discharge, and encounters Although most of the medical record information can be destroyed after a certain time constraint, this information is permanently retained in the facility's master patient index (MPI).
Which of the following is NOT a benefit of the electronic document management system in the HIM Department? decreased use of computer technology multiuser simultaneous access online availability of information system security and confidentiality
decreased use of computer technology Utilization of an electronic document management system (EDMS) involves increased use of computer technology. An EDMS makes it possible to scan documents that originated on paper and perform indexing, storage, and retrieval functions electronically.
The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should issue a copy of the birth certificate from the patient's record. issue a copy of the newborn's record. direct the request to the attending physician. direct the request to the state's office of vital records.
direct the request to the state's office of vital records. Official birth records are maintained by the state.
Electronic health record built-in tools that can make data capture easier include all but which one of the following? data dictionaries automated quality measures flow process charts clinical decision support systems
flow process charts A flow process chart depicts a sequence of actions for a particular process. It is essential in the continuous improvement process.
An example of a primary data source is the physician index. health record. hospital statistical report. cancer registry.
health record. The health record is a primary source because it contains patient information documented by caregivers who participated in the care of the patient. Indices and registries are considered secondary data sources.
Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a(an) interfaced system. integrated system. standard. OLAP.
interfaced system. Interfaces make it possible for organizations to exchange data.
Under the Patient Self-Determination Act of 1990, evidence of advance directives is required to be documented in the health record. requires a doctor's approval. is not required to be documented in the health record. must be prepared by an attorney.
is required to be documented in the health record. According to the Patient Self-Determination Act of 1990, advanced directives are required to be documented in the health record.
Which of the following features should NOT be considered when designing screens to capture quality health data? built-in alerts to notify users of possible errors left to right and bottom to top formatting the use of abbreviations on data fields a prompt for more information
left to right and bottom to top formatting It is not necessary to consider formatting because most EHRs come equipped with forms and templates.
Which of the following is NOT a data retrieval tool? SQL light pen color, animation, sound, icons screen design
light pen Data cannot be retrieved with a light pen.
A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data? overwriting the backup tapes overwriting data with a series of characters disk reformatting magnetic degaussing
magnetic degaussing Computerized data can be erased by neutralizing the magnetic field. This destruction method is called magnetic degaussing.
Which of the following is NOT a major management challenge in the storage and retention of electronic health record systems? ensuring that health information can be retrieved in a timely manner keeping technology updated in order to retrieve data following state and federal laws and accreditation requirements when developing retention and destruction policies maintaining the paper-based storage system
maintaining the paper-based storage system Maintaining a paper-based storage system is not a challenge with electronic health record systems.
For a health care facility to meet its document destruction needs, the certificate of destruction should include all but which of the following elements? location of destruction patient notification unique and serialized transaction number acceptance of fiduciary responsibility
patient notification Patient notification is not required for document destruction.
Which of the following is NOT a factor to consider when developing a record retention program? legal requirements as determined by statute of limitations reimbursement guidelines cost of space to maintain paper records record usage in the facility determined by health care provider activity
reimbursement guidelines It is not necessary to consider reimbursement guidelines when developing a record retention program.
Concern for health data loss and misuse within the HIM Department requires that the health information practitioner evaluate all but which of the following? policies and procedures developed to safeguard privacy and security use of a back-up system security controls and access privileges of staff salary for the database administrator
salary for the database administrator The database administrator's salary is irrelevant to the evaluation of health data loss and misuse.
Which of the following is NOT an advantage of an electronic document management system? scanned record data can be manipulated workflow can be controlled electronically paper record can be stored digitally user has immediate access to health record
scanned record data can be manipulated The user cannot manipulate the data because the document is stored as an image.