Chapter 2 EHR Exam

CE is the abbreviation for

Covered entity.

Disclosure of which of the following conditions requires a specific authorization from the patient other than TPO?

Drug abuse

How many Americans are part of Medicare and Medicaid program?

More than 90 million

OCR is the abbreviation for

Office for Civil Right.

PHI is the abbreviation for

Protected health information.

Electronic health records are considered to have signification advantages, including all of following except:

Reduced costs.

EHR is the abbreviation for:

Electronic Health Record.

--------- is the process of encoding information in such a way that only the person (or computer) with the key can decode it.

Encryption

A _____is an impermissible use or disclose under Privacy Rule that compromises the security or privacy of PHI.

Breach

DRS is the abbreviation for

Designated Record Set.

Which of the following is systematic, logical, and consistent recording of a patient's health status in medical record?

Documentation

Which act requires publicly traded corporation to attest that their financial management is sound? 2.9

Sarbanes-Oxley Act

All of the following are used for medical record except:

Scheduling.

When completely implemented, HIPAA National Identifiers will be available for:

employers, provider and health plans-All of these included

An encounter is defined as

face-to-face meeting between patients and provider.

An authorization to disclose PHI that a patient signs must have all except:

signature of the nurse who treated the patient.

The minimum necessary standard means to:

take reasonable safeguard to protect PHI.

Which agency advices against using a patients' name in the body of medical report?

Association for health care Documentation Integrity (AHDI)

NPI is abbreviation for

National Provider Identifier.

The health care fraud and abuse control program was created by

HIPAA.

HIPAA identifies three types of covered entities (2.3)

health plans, clearinghouses, and providers

Which of the following acts provided additional funding to strengthen the tools that the DOJ and HHS used to pursue fraud investigating?

ACA

Disclosure of which of the following conditions requires a specific authorization from the patient other than TPO?

AIDS

Which of the following is an action misuses money that the government has allocated?

Abuse.

________ is activity pf copying files to another medium so that they will be preserved in case the originals are no longer available.

Backing Up

With HIPAA a transactions standard set, each standard is labeled with a

Both name and number.

Which of the following are organizations that work for covered entities but are not themselves covered entities?

Business associates

E/M is the abbreviation for:

Evaluation and management.

Which of the following laws prohibits submitting a fraudulent claims.?

FCA

Which of the following act strengthened the provision of the FCA? 2.9

FERA.

A complete H&P (history and physical) is documented with how many types of information.?

Four (The chief complaint / the H&P examination / diagnosis / treatment plan.)

HIPAA contains how many provisions (title) that focus on various aspects of health care?

5

Which of the following is an example of patients' protected health information?

Address - Birthdate - Fax number - all these example of PHI.

Which of the following conditions requires a specific authorization from patient other than for TPO?

Alcohol abuse

The ----------make it illegal to knowingly offer incentives to include referral.

Antikickback statute

When are covered entities required to give patient their notice of Privacy practice?

At first contact or encounter

PHI may be released without the patients' authorization in all situation except:

Attorneys.

CMS stand for:

Center for Medicare and Medicaid Service.

During process of informed consent, the physician advises the patient as to all of the following except:

Cost.

-------is deception with intent to benefit from the behavior.

Fraud

_______makes it possible for physician and health plan to exchange electronic data using a standard format. (2.7)

HIPAA Electronic Transaction and Code Sets (TCS)

--------------regulates the use and disclosure of patients protected health information.

HIPAA Privacy Rule

Which of the following requires CEs (covered entity) to establish safeguards to protect PHI.?

HIPAA Security rule

Under which act can a patient restrict the access of health plans to their medical record if they pay for service in full at the time of visit?

HITECH.

Disclosure of which of the following conditions requires a specific authorization from the patient other than TPO?

HIV

HIPAA is abbreviation for:

Health Insurance Portability and Accountability Act.

_____are number of predetermined length and structure, such as people social security number.

Identifiers

The responsibility of licensed health care professional to observe state medical standards of care is called:

Medical Professional Liability.

Patients' medical record must document all of the following except:

Next of kin (include allergies, diagnosis, signature of provider)

What group is charged with detecting health care fraud and abuse?

OIG

OIG is abbreviation for

Office of the Inspector General.

The ACA requires the adoption of ----------for each of the HIPAA standard transactions.

Operating Rules

Which of the following is required for releasing protected health information for reasons other than TPO?

Patient's signed authorization

A -------is a person who make an accusation of fraud or abuse.

Relator

Disclosure of which of the following conditions requires a specific authorization from the patient other than TPO?

Schizophrenia

Which of the following is not a type of history documentation the chart?

Spiritual.

Which of the following laws make it illegal for physicians to have financial relationships with clinic to which they refers patients?

Stark Rules.

SOAP is the abbreviation for which?

Subjective / Objective / Assessment / Plan.

In a SOAP format, which of the following is information from the patient?

Subjective.

Which of the following acts contains additional provision concerning the standard for electronic transmission of health care data?

TCS (HIPAA Electronic Health Care Transactions and Code Sets.)

Under HIPAA, patients' PHI may be shared for ------without their authorization.

TPO -treatment, payment, healthcare operation

The Electronic equivalent of a business document is calledan

Transaction.

A progress report documents a patients'

Type of treatment still needed and duration.

All following should be completed on note except:

Verification

Breach notification must contain all except:

a description of the damages awarded for ill consequences from the breach.

A Valid authorization must include except:

a statement about whether the CE is able to base prescriptions on authorization.

Patient have the right to ------- and inspect their complete health record.

access

The document notifying an individual of a breach is called a

breach notification

Under the Affordable Care Acts providers can be subject to all except ----------before they are allowed to bill Medicaid/ Medicare program.

interviews (finger printing / background checks / site visit but not interviews)

Which of the following can be used by providers to transmit claims in the proper format for carriers?

clearing house.

Patient information may be released without patients' authorization under which of the following circumstances?

court orders / research / statutory reports.-All of the above

HIPAA Electronic Health care Transaction and Code set standard specify certain code sets for all except:

facilities.

What is the most important strategy a medical practice can use to ensure regulations are being followed? (2.10)

having a compliance plan in place

All good tips for selecting good passwords except:

keep your password secret and never changed it.

Some state status differs in the following areas except:

legal size of practice.

When protected health information is shared, which of the following should be observed?

minimum necessary standard

When leaving a message on a patients' answering machine, what is to be followed?

minimum necessary standard.

For release of PHI for treatment, payment and health care operations:

no authorization is required from the patient.

Discharge summaries include all of following except:

physical examination

Worker compensation cases may require release of records to all except:

the employee's direct supervisor.

TPO is an abbreviation for

treatment, payment, and healthcare operation.