Practice Exam Domain 6 (RHIT Exam)

Which of the following individuals may authorize release of information?

A married 15-year-old father

Changes to health record entries are:

Acceptable in certain circumstances

Community Hospital is planning implementation of various elements of the EHR in the next six months. Physicians have requested the ability to access the EHR from their offices and from home. What advice should the HIM director provide?

Access con be permitted providing that appropriate safeguards are put in place to protect against threats to security

A hospital currently includes the patient's Social Security number on the face sheet of the paper health record and in EHR. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say they need the information for identification and other purposes. Given this situation, what should the HIM director suggest?

Avoid displaying the number on any document, screen, or data collection field

Which of the following activities is considered an unethical practice?

Backdating progress notes

A subpoena duces tecum compels the recipient to:

Bring records to a legal proceeding

Hospital physical documents relating to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned:

By the hospital

Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO?

Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned

Which of the following ethical principles is being followed when an health information management professional ensures that patient information is only released to those who have a legal right to access it?

Correct Answer: Beneficence Wrong Answer: Nonmaleficence

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identity the components of the legal health record?

Correct Answer: Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records Wrong Answer: Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice

A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct?

Correct Answer: No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient Wrong Answer: Yes; HIPAA only requires that current records be produced for the patient

Physician orders for DNR and DNI should be consistent with

Correct Answer: Patient's bill of rights Wrong Answer: Patient's advance directive

A home health agency plans to implement a computer system whereby its nurses document home care services on a laptop computer taken to the patient's home. The laptops will connect to the agency's computer network. The agency is in the process of identifying strategies to minimize the risks associated with the practice. Which of the following would be the best practice to protect laptop and network data from a virus introduced from an external device?

Correct Answer: Personal firewall software Wrong Answer: Session terminations

A patient requests a copy of his health records. When the request is received, the HIM clerk finds that the records are stored off-site. Which of the following actions must the hospital take to be in compliance with HIPAA regulations?

Correct Answer: Provide copies of the records within 60 days Wrong Answer: Provide copies of the records within 30 days

A patient requests copies of her medical records in an electronic format. The hospital does not maintain all of the designated records in an electronic format. How should the hospital respond?

Correct Answer: Provide the records in paper format only Wrong Answer: Inform that patient that PHI cannot be sent electronically

Which of the following definitions best describes the concept of confidentiality?

Correct Answer: The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose Wrong Answer: The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?

Correct Answer: There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice Wrong Answer: HIPAA allows only the use of the patient's first name

The legal health record:

Correct Answer: Will be disclosed upon request Wrong Answer: Must consist in part on paper

The right of an individual to keep personal health information from being discclosed to anyone is a definition of:

Correct Answer: privacy Wrong Answer: confidentiality

What is the term used most often to describe the individual within an organization who is responsible for protecting health information in conjunction with the court system?

Custodian of records

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do?

Determine what information was printed and why

What types of covered entity health records are subject to the HIPAA privacy regulations?

Health records in any format

The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence?

Identification of the record as the one subpoenaed

Which of the following ethical principles is being followed when an health information management professional applies rules fairly to all?

Justice

Which of the following is an example of an advance directive?

Living will

Community Hospital is implementing a hybrid record. Some documentation will be paper-based and digitally scanned post-discharge. Other parts of the record will be totally electronic. The Medical Record Committee is discussing how interim reports in the health record should be handled. Some on the committee think that all interim reports should be discarded and only the final reports retained in the scanned record. Others take the opposite position. What should the HIM director recommend?

Maintaining all interim reports provides the greatest measure of security

The admissions director maintains that a notice of privacy practices must be provided to the patient on each admission. How should the HIM director respond?

Notice of privacy practices is required on the first provision of service

An individual who brings a lawsuit is called the:

Plaintiff

Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report?

Present an authorization that at least one of them (Ted or Mary) has signed

An individual's right to control access to his or her personal information is known as:

Privacy

Which of the following is a core ethical obligation of health information professionals?

Protecting patients' privacy and confidential communications

A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do?

Review the subpoena and appear at the time and place supplied to give testimony

A hospital HIM department receives a subpoena duces tecum for records of a former patient. When the health record technician goes to retrieve the patient's health records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena?

Submit a certification of destruction in response to the subpoena

When correcting erroneous information in a health record, which of the following is not appropriate?

Use black pen to obliterate the entry