CMAA Medical Records Management 5 — Questions and Answers
Question 1: Which method is recommended for permanently destroying paper medical records containing PHI?
- Recycling through a standard paper bin
- Cross-cut shredding or incineration (Correct answer)
- Placing in a locked dumpster
- Returning them to the patient
Correct answer: Cross-cut shredding or incineration
Cross-cut shredding or incineration ensures that PHI on paper cannot be reconstructed and is the HIPAA-compliant disposal method.
Question 2: An EHR audit trail is important because it:
- Automatically corrects errors in documentation
- Records who accessed or modified a patient record and when (Correct answer)
- Transmits records to insurance companies
- Converts handwritten notes to digital text
Correct answer: Records who accessed or modified a patient record and when
An audit trail logs all access and changes to electronic health records, providing accountability and supporting compliance investigations.
Question 3: What is the standard retention period for adult patient medical records under most US state guidelines?
- 1 year after last visit
- 3 years after last visit
- 5 to 10 years after last visit or last date of service (Correct answer)
- Records must be kept permanently
Correct answer: 5 to 10 years after last visit or last date of service
Most states require adult medical records to be retained for 5 to 10 years from the date of last service, though requirements vary by state.
Question 4: Which of the following situations requires a written authorization from the patient before releasing PHI?
- Disclosing records to the treating physician's covering partner
- Sending records to the patient's attorney for a personal injury lawsuit (Correct answer)
- Reporting a communicable disease to the state health department
- Sharing records with another treating provider for continuity of care
Correct answer: Sending records to the patient's attorney for a personal injury lawsuit
Disclosing PHI to an attorney for legal purposes (such as a personal injury lawsuit) requires specific written patient authorization.
Question 5: In medical record documentation, what is the correct way to make an error correction in a paper record?
- Use correction fluid (white-out) to cover the error
- Draw a single line through the error, write the correct information, date it, and initial it (Correct answer)
- Erase the error completely and rewrite
- Remove and replace the entire page
Correct answer: Draw a single line through the error, write the correct information, date it, and initial it
A single line through the error preserves the original entry for legal integrity, while the correction, date, and initials show who made the change and when.
Question 6: What is a 'release of information' (ROI) log used for in a medical office?
- Scheduling patient appointments
- Tracking all disclosures of PHI to document compliance (Correct answer)
- Recording insurance claim submissions
- Logging employee training completion
Correct answer: Tracking all disclosures of PHI to document compliance
An ROI log tracks every instance of PHI disclosure, documenting who requested the information, what was sent, and when, to demonstrate HIPAA compliance.
Question 7: Which federal act gives patients the right to request an accounting of disclosures of their PHI?
- The Freedom of Information Act (FOIA)
- The Health Insurance Portability and Accountability Act (HIPAA) (Correct answer)
- The Americans with Disabilities Act (ADA)
- The Clinical Laboratory Improvement Amendments (CLIA)
Correct answer: The Health Insurance Portability and Accountability Act (HIPAA)
HIPAA grants patients the right to request an accounting of certain disclosures of their PHI made by a covered entity over the past six years.
CMAA Medical Records Management 5
Which method is recommended for permanently destroying paper medical records containing PHI?