RHIT Record Content Management 3 — Questions and Answers
Question 1: Which element is required for a valid informed consent document in a health record?
- Witness must be a licensed nurse
- Description of risks, benefits, and alternatives of the procedure (Correct answer)
- Patient's insurance information
- Attending physician's countersignature within 24 hours
Correct answer: Description of risks, benefits, and alternatives of the procedure
Valid informed consent must include the nature of the procedure, its risks, benefits, and alternatives so the patient can make a voluntary decision.
Question 2: A facility's incomplete record rate is consistently above benchmark. Which policy change would MOST directly address this problem?
- Increase the number of HIM staff assigned to coding
- Implement suspension of clinical privileges for physicians with delinquent records (Correct answer)
- Require nurses to complete physician documentation
- Reduce the legal medical record definition
Correct answer: Implement suspension of clinical privileges for physicians with delinquent records
Suspending clinical privileges for physicians with delinquent records is the most effective enforcement mechanism recognized by accreditation bodies.
Question 3: What does the term 'legal health record' refer to?
- Records subpoenaed for court proceedings
- The subset of health information defined by the organization as the official business record (Correct answer)
- All data stored in the EHR including drafts and metadata
- Records protected by attorney-client privilege
Correct answer: The subset of health information defined by the organization as the official business record
The legal health record is the organization-defined subset of health information that constitutes its official business record for legal and disclosure purposes.
Question 4: A record is flagged because a physician's late entry was added three days after service. What is required to maintain the integrity of this late entry?
- The entry should be deleted and re-entered with today's date only
- The entry must be labeled as a late entry with the current date and time of documentation (Correct answer)
- A supervisor must co-sign the late entry
- The entry is inadmissible and must be excluded from the record
Correct answer: The entry must be labeled as a late entry with the current date and time of documentation
Late entries must be clearly labeled as such, with the actual date and time of documentation noted, while also referencing the date of service.
Question 5: Under the HIPAA Minimum Necessary standard, a request for PHI from another treating provider should be:
- Denied unless the patient is present to authorize
- Honored with the full record since treatment is a permitted purpose
- Limited to only the information reasonably needed to accomplish the treatment purpose (Correct answer)
- Routed through the hospital's legal department first
Correct answer: Limited to only the information reasonably needed to accomplish the treatment purpose
Even for permitted treatment purposes, the Minimum Necessary standard requires limiting disclosure to what is reasonably needed for that specific purpose.
Question 6: Which accreditation body publishes the Comprehensive Accreditation Manual for Hospitals (CAMH) which includes medical record standards?
- Centers for Medicare & Medicaid Services (CMS)
- The Joint Commission (TJC) (Correct answer)
- National Committee for Quality Assurance (NCQA)
- American Health Information Management Association (AHIMA)
Correct answer: The Joint Commission (TJC)
The Joint Commission publishes the CAMH, which sets medical record content and completion standards for accredited hospitals.
Question 7: A patient requests to amend their health record, claiming a diagnosis is incorrect. The provider reviews and disagrees. What should the facility do?
- Correct the record as requested to avoid legal liability
- Deny the request and provide no further action
- Deny the amendment but add the patient's statement of disagreement to the record (Correct answer)
- Transfer the record to another provider for a second opinion
Correct answer: Deny the amendment but add the patient's statement of disagreement to the record
Under HIPAA, if an amendment is denied, the patient has the right to submit a statement of disagreement that must be appended to the record.
RHIT Record Content Management 3
Which element is required for a valid informed consent document in a health record?