2014CRIS Test
Please circle the best answer.
Section A: MEDICAL RECORDS THEORY
- Who owns the medical record?
a)The patient
b)The physician
c)The heath care facility
d)The Federal Government under HIPAA
- The tool most often used to gather a complete medical record is the :
a)Conditions of Admission
b)Notice of Privacy Practices
c)Master Patient Index
d)Information Management Plan
- The purpose(s) of the medical record is/are:
a)To assist in further research and education
b)To assist in protecting the legal rights of the patient and healthcare facility
c)To provide analysis, study and evaluate care given to the patient
d)All of the above
Section B: RELEASE OF INFORMATION QUESTIONS (ROI)
- Which of the following may be considered an improper disclosure of protected health information?
a)Releasing records to a requester for legal purposes without a signed patient
authorization.
b) Accidentally releasing the wrong patient’s records to a requester.
c)Releasing dates of service to a requester if the service dates were not
authorized.
d)All of the above
- Which of the following is not required on a HIPAA compliant authorization?
a)Name of the healthcare provider
b)Identity of the patient
c)Any fees associated with the release
d)Signature of the patient or his/her personal representative
e)Expiration date or event
6.A patient presents to the HIM Department requesting information about a recent biopsy. The patient reveals he wants to know details about the procedure and specifics regarding the specimen removed. The patient should be advised torequest a copy of:
a)Entire record
b)Operative and Pathology Report
c)History and Physical
d)None of the above
7.Some attorneys send a courtesy deposition letter prior to issuing a subpoena. Can you release information without authorization if you have the deposition letter prior to receiving the subpoena?
a)Yes
b)No
8.A facility may put all the elements of a valid authorization on one form to cover HIPAA, chemical dependency, HIV and genetic testing.
a) True
b) False
9. When a patient completes an authorization, can they simply put “at the request of the patient” as a disclosure purpose?
a)Yes
b)No
10.With a court order (signed by a judge), is an authorization signed by the patient or personal representative required?
a)Yes
b)No
11.Which of the following hospital departments have access to a patient’s medical records without authorization? (please circle all that apply)
a) Nursing unit – patient readmitted to hospital
b) Cook in food service – reviews for friend
c) Medical Staff Physician not treating patient or consulting – reviews because
patient isa former patient
d) Quality Management Personnel – reviews for hospital statistics
e) Human Resources Receptionist – reviews for an employee
f) Risk Management – reviews for administrative issue
12. The PRO or QIO (Peer Review Organization or Quality Improvement Organization) contracted with CMS (Centers for Medicare & Medicaid Services) requests copies of medical records. Are they allowed access to the medical record without an authorization for a patient with schizophrenia??
a)Yes
b)No
13.What is the difference between a patient’s request and a patient’s authorization?
a)There is no difference.
b)The request is verbal and the authorization is in writing.
c)The request is in writing and asks that records be released; the authorization is the written permission to do so.
14.If there is a breach of protected health information, which of the following legal actions may be taken?
a)Civil Action
b)Criminal Action
c)Both
d)Neither Civil or Criminal Action
15.Birth and death certificates may be released by the hospital.
a)True
b)False
16.What records do you copy for a Medicare request?
a)Records specified for dates requested
b)The entire record
c)Current records only
Section C: Application/Practicum Questions
17.Dr. Grant and Dr. Palmer work at the same hospital. Dr. Grant is the only physician
treating Dr. Palmer’s son, Jerry, who is 18 years old and able to sign for himself. Dr. Palmer signs an authorization and demands to see his son’s records. He is a well-known physicianat the hospital. Does he have a right to access this medical record without authorization?
a)Yes
b)No
18.A female patient has expired in your hospital. Your state law specifies that in the case of a deceased patient, all of the following individuals may have equal access to the patient’s records: Executor of the estate, Administrator of the will, Surviving Spouse, Surviving Parents, and Surviving Children. She was a widow with two (2) daughters, Sally and Beth. Both daughters admitted their mother into the hospital and are listed on the chart as next of kin. Beth is the executor of the will. Sally callsyou, explaining that the sisters are in the midst of an argument concerning their mother’s will. She asks you to copy the records for her (she offers to come in to sign the release) and also asks that you deny such release to her sister, Beth. You should tell her:
a)To write a letter stating why Beth should not have access to the information.
b)To bring proof of her identity for the records before she picks them up.
c)That Beth has a right to receive a copy of the records as executor and as a surviving child.
d)B & C
19. A woman calls to tell you she has received a bill for outpatient services (which she has already spoken to the billing department about), but was never a patient at the hospital. She suspects someone has fraudulently used her name and insurance cards. She requests a copy of the record “out of curiosity”. You should tell her:
a)You will speak to the Manager about correcting the situation so that the record does not appear under her name, but you cannot release medical information related to another person without consent of the patient.
b)She is entitled to the information since the person used her name.
c)You cannot give it to her since you know the situation, but if she calls back and speaks to someone else, she can probably get it.
20.A man calls and says that he wants his history and physical sent to the insurance company for consideration of a life insurance application. “One minor thing…if it has anything in there about my history of smoking, just cover that up when you copy it, OK?” You tell him:
a)You must copy the report in full, as it appears in the record. You apologize that you cannot fulfill his special request, but this would be considered tampering with his medical record.
b)You can fold the report when you copy it so it will not appear on the copy.
c)You tell him to have the records sent to him, so he can make any changes he wants and then send it off to the insurance company.
21.A patient signs an authorization for release of medical records and you notice the patient was treated in the chemical dependency program. The authorization you received is a general authorization. You:
a)Call to tell the patient that it is a special circumstance and ask whether you should still send the records.
b)Send the records but mark them with a special stamp.
c)Send a letter requesting special authorization for this particular situation, and enclose the special authorization that’s required.
22.A nurse who works in the hospital comes in the HIM department to request copies of the medical record of her mother-in-law, who now resides in a local nursing home. The nurse tells you she has power of attorney and needs the records for personal reasons.
a)You request a copy of the power of attorney to make sure that this includes power of attorney for medical care. Then you follow the appropriate release procedure.
b)You send the request directly to the nursing home; asking them to verify whether the daughter-in-law nurse has power of attorney.
c)You only need to have the authorization signed, since the nurse is wearing an identification badge and is employed by the hospital.
23.You are working in a small town where everyone knows everyone else. A mother comes in and asks for copies of her daughter’s medical records. The mother explains that her daughter is 20 years old and attends college out of town. The mother also explains that they are changing HMOs, so she needs the records to take to the new clinic. The authorization is signed by the mom. You should:
a)Tell the mom you need her daughter’s authorization to release the records to the mother.
b)Tell the mom that she can have the new clinic request the records directly for treatment purposes.
c)Copy the records, put them in a sealed envelope and tell the mom not to open the envelope before she brings them to the new clinic.
d)A & B.
24.You are working in a children’s hospital. You have received a request from the mother of a 17-year-old married patient for his medical records. The parents consented for the 17-year-old to marry and marriage is grounds for emancipation in the state. The mother wants the records to complete the personal health record she has compiled and wishes to give to her son. You should:
a)Copy the records because the age of majority in the state is 18.
b)Tell the mom the son must sign the authorization now that he is an emancipated minor.
c)Tell the mom her son’s wife must sign the authorization now that she is the next of kin.
25.A man walks into the Health Information Management Department where you work. He is asking for copies of his now deceased father’s records. You should:
a)Copy the requested records for the son and bill him for the pages.
b)Tell the son you need a signature from the deceased patient’s wife.
c)Refuse the request because you don’t know if the patient is deceased.
d)Ask for a copy of court documents appointing him executor or administrator of the father’s estate. If there is no executor or administrator, ask for a copy of the death certificate and determine who is “next of kin”or has access to a deceased patient’s records in your state before you copy the records.
26.An insurance company is requesting the medical records of a person who wants to purchase life insurance with this company. The authorization submitted is invalid. But the agent has called you three times about this request and is begging you to copy the records. You should:
a)Copy the records while he tries to get a new authorization from the patient.
b)Tell the agent you need a valid authorization before you can copy the records.
c)Call the patient and ask if it is OK for you to copy his medical records for the agent.
d)Copy the records and mail the records to the home office of the insurance company instead of giving them directly to the agent.
27.You are working in a clinic close to your home. You are filling in for a vacationing employee, who is the only employee at this location. A request and valid authorization for the medical records of your neighbor is in the pile of requests you have to process today. You should:
a)Complete the request for records. Review as little as possible. Any information you learn while processing the request must be kept confidential and safeguarded.
b)Give it to the medical secretary and ask her to do it since you know the patient.
c)Refuse to process the request.
d)Call your neighbor and ask if it is ok if you send the medical records.
28.Erica Smith, 19 years old, has submitted an authorization asking for a copy of an x-ray
taken when she was 5 years old at another hospital. The records she is requesting are in her chart at your hospital. The designated record set in your healthcare facility includes outside records used for treatment purposes. Are you allowed to release these records?
a)Yes
b)No
29.The non-custodial parent requests a copy of their child’s medical record. The parent provides documentation that they are indeed the child’s parent. There is no notice of child abuseor a restraining orderin the file. The non-custodial parent has a right to access the medical record.
a)True
b)False
30.A doctor requests copies of his wife’s records, whom he is not treating and she has no medical condition that would limit her ability to sign. You refuse to copy and release the records because you do not have a signed authorization from the wife.
a)True
b)False
31.A minor’s mother calls your HIM Department explaining that her family moved and the school needs a copy of her child’s immunization records to begin school the next day. She states that she can fax a letter with full instructions. Immunization records are required for a child to begin school in both the old and the new state where the minor resides. What should you do?
a)Ask the mother to fax her requestwith the minor’s full name, identification data & recipient instructions so that you may process the request right away.
b)Tell the mother an authorization is required per HIPAA and her written request will not be good enough.
32.One of the HIM employees brings a chart to you and asks you to copy some of the records. This employee has no authorization. What do you do?
a)You tell the employee that you need a HIPAA compliant authorization before you can copy the record.
b)Copy the record, because she wouldn’t ask you to copy something if she didn’t need it.
c)Tell the HIM manager the employee is doing something unethical.
d)Put it on your pile and “forget” to do it.
33.You have access to the computer at your facility. You forgot your password, but the computer next to your desk is on and no one is working there. Should you use that computer?
a)Yes. The computer has the same programs, so it is OK for you to use this computer.
b) No. You call the person in charge of passwords at your facility,and ask for help .
34.A revocation of an authorization allows the patient to change his/her mind about the release of their medical records if it has not been acted upon yet.
a)True
b)False
35.You are working for a facility that does not release outside records for ROI requests. If an attorney says he needs to obtain records from all the facilities in which the patient was treated and asks you to give him the names of the facilities for any “other records” in the chart, should you provide a list?
a)No – where a patient was seen is protected health information, and should be kept confidential.
b)Yes – since they requested records and sent an authorization they have a right to know even if it is against hospital policy.
Section D: HIPAA QUESTIONS
36.“Designated Record Set” includes the following information regarding health care
decisions:
a)Medical records
b)Billing records
c)Claims information
d)All of the above
37. Which of the following types of information does HIPAA’s Privacy Rule protect?
a)Oral health information
b)Health information in paper form
c)Health information in electronic form
d) All of the above
38. HIPAA’s Privacy Rule gives a patient the right to access their:
a)Medical record only
b)Designated Record Set
c)Itemized bill only
d)Insurance records only
39.Can a healthcare facility deny a patient’s request to amend or correct his/her medical record?
a)Yes
b)No
40.What are required disclosures under the HIPAA Privacy Rule?
a)Disclosures to the patient
b)Disclosures to another healthcare facility
c)Disclosures to the Secretary of HHS for purposes of compliance
d)A & C
41. Which of the following is not a public priorityexception to HIPAA’s Privacy Rule?
a)Requests for child or elder abuse investigation
b)Public health reporting
c)Law enforcement purposes
d)Insurance company requests
e)Coroner requests
42. For which reason under HIPAA’s Privacy Rule can protected health information be disclosed without authorization?
a)Treatment
b)Payment
c)Health care operations
d)All of the above
43. Under HIPAA, a personal representative is an individual who is authorized to sign an authorization on behalf of the patient. Choose all possible personal representatives:
a)Parent of a minor child
b)Legal guardian of a minor child
c)Patient’s attorney
d)Person who holds Durable Power of Attorney for Healthcare
44.A person who is a caregiveror bill payer for a patient has the right to access the records about that deceased patient’s death.
a) True
b)False
45.If a patient brings a personal flash drive to the facility and asks you to copy his record onto the flash drive, HIPAA requires that the facility must honor the patient’s request to put the data onto the patient’s personal device.
a)True
b)False