RHIT Record Content Management 5 — Questions and Answers
Question 1: Which of the following is the BEST example of secondary use of health record data?
- A physician reviewing a patient's allergy list before prescribing
- A researcher using de-identified patient data to study disease trends (Correct answer)
- A nurse documenting vital signs during a patient's visit
- A pharmacist verifying a medication order
Correct answer: A researcher using de-identified patient data to study disease trends
Secondary use refers to using health data for purposes other than direct patient care, such as research, quality improvement, or public health reporting.
Question 2: What is a key difference between the designated record set (DRS) and the legal health record?
- The DRS is used only for billing purposes
- The DRS is broader and includes records used to make decisions about an individual; the legal health record is the organization's defined official record (Correct answer)
- The legal health record includes all metadata and audit logs; the DRS does not
- There is no difference; the terms are interchangeable under HIPAA
Correct answer: The DRS is broader and includes records used to make decisions about an individual; the legal health record is the organization's defined official record
The DRS, defined by HIPAA, is a broader set of records used in decision-making, while the legal health record is the facility-defined official business record.
Question 3: A patient's records are requested via subpoena. The HIM professional should FIRST:
- Release the records immediately to comply with the court order
- Consult with the facility's legal counsel before releasing any information (Correct answer)
- Obtain a written patient authorization before proceeding
- Notify the patient's insurance company of the subpoena
Correct answer: Consult with the facility's legal counsel before releasing any information
The HIM professional should consult legal counsel first, as a subpoena alone may not override state privacy protections without a court order.
Question 4: Which document type is used by a physician to transfer the responsibility for a patient's care to another physician within the same facility?
- Discharge summary
- Transfer note (Correct answer)
- Referral letter
- Consultation report
Correct answer: Transfer note
A transfer note documents the reason for and details of transferring a patient's care from one physician to another, including within the same facility.
Question 5: Under the HIPAA Privacy Rule, which of the following does NOT require patient authorization for disclosure?
- Disclosure to a life insurance company for underwriting
- Disclosure to a marketing firm for promotional purposes
- Disclosure to a public health authority for disease reporting (Correct answer)
- Disclosure to an employer for pre-employment screening
Correct answer: Disclosure to a public health authority for disease reporting
Disclosures to public health authorities for mandated disease reporting are a permitted use under HIPAA that does not require patient authorization.
Question 6: A facility's record destruction policy calls for shredding paper records. Which additional step is required to properly document this process?
- Notifying each patient whose records are destroyed
- Maintaining a certificate of destruction that lists what was destroyed, when, and by whom (Correct answer)
- Obtaining court approval before destroying any records
- Archiving a photocopy of each destroyed record
Correct answer: Maintaining a certificate of destruction that lists what was destroyed, when, and by whom
A certificate of destruction provides a legal record that documents the destruction process, protecting the facility from liability.
Question 7: Which of the following is a characteristic of the problem-oriented medical record (POMR)?
- Documents are organized by the department that created them
- All entries are arranged in reverse chronological order
- Care is organized around a numbered problem list with SOAP-format progress notes (Correct answer)
- Records are maintained exclusively in electronic format
Correct answer: Care is organized around a numbered problem list with SOAP-format progress notes
The POMR uses a numbered problem list as an index, and progress notes are written in SOAP (Subjective, Objective, Assessment, Plan) format for each problem.
RHIT Record Content Management 5
Which of the following is the BEST example of secondary use of health record data?