CMAA Medical Records Management 4 — Questions and Answers
Question 1: Under HIPAA, which of the following is NOT considered protected health information (PHI)?
- A patient's diagnosis documented in the chart
- A patient's name linked to their condition
- Aggregated de-identified statistical data (Correct answer)
- A patient's date of birth combined with their address
Correct answer: Aggregated de-identified statistical data
Properly de-identified and aggregated statistical data does not qualify as PHI because it cannot be used to identify an individual.
Question 2: What is the purpose of a 'chart deficiency' notice sent to a physician?
- To notify the physician of a billing error
- To alert the physician that required documentation is incomplete or missing (Correct answer)
- To request a new patient referral
- To schedule a medical record audit
Correct answer: To alert the physician that required documentation is incomplete or missing
A chart deficiency notice informs the physician that specific documentation required for a complete medical record has not been completed.
Question 3: Which record storage system arranges files so that the last two digits of the patient ID determine the primary filing location?
- Straight numeric filing
- Alphabetic filing
- Terminal digit filing (Correct answer)
- Subject filing
Correct answer: Terminal digit filing
Terminal digit filing uses the last two (or more) digits of the ID as the primary sort key, distributing files evenly across shelves.
Question 4: A patient requests a copy of their medical record but asks that the information NOT be sent to their insurer. What must the practice do?
- Deny the request because insurers have automatic access
- Honor the request and restrict disclosure to the insurer (Correct answer)
- Notify the insurer before complying
- Require a court order before restricting disclosure
Correct answer: Honor the request and restrict disclosure to the insurer
Under HIPAA, patients have the right to request restrictions on how their PHI is disclosed, and the practice must agree to reasonable restrictions.
Question 5: What does the term 'legal health record' (LHR) refer to?
- Records subpoenaed by a court
- The subset of health information that constitutes the official business record for legal and disclosure purposes (Correct answer)
- Any document signed by the treating physician
- Electronic records only, excluding paper documents
Correct answer: The subset of health information that constitutes the official business record for legal and disclosure purposes
The legal health record is the designated set of documents that represent the official record of patient care and is used for legal, regulatory, and disclosure purposes.
Question 6: Which of the following best describes the 'minimum necessary' standard under HIPAA?
- Releasing only the PHI reasonably needed to accomplish the intended purpose (Correct answer)
- Releasing the entire medical record whenever requested
- Providing PHI only to treating physicians
- Limiting PHI access to the practice administrator
Correct answer: Releasing only the PHI reasonably needed to accomplish the intended purpose
The minimum necessary standard requires covered entities to make reasonable efforts to disclose only the PHI needed for the specific purpose of the disclosure.
Question 7: A medical office receives a subpoena for a patient's records. What is the FIRST step the administrative assistant should take?
- Immediately copy and send all records to the requesting attorney
- Notify the physician and consult the office's legal counsel before releasing records (Correct answer)
- Destroy any sensitive documents before complying
- Contact the patient's insurer for authorization
Correct answer: Notify the physician and consult the office's legal counsel before releasing records
The administrative assistant should notify the treating physician and involve legal counsel to ensure proper authorization and compliance before releasing any records.
CMAA Medical Records Management 4
Under HIPAA, which of the following is NOT considered protected health information (PHI)?