Medical Records Management Test Questions
Course Introduction
Medical Records Management focuses on the systematic organization, maintenance, and protection of patient health information in healthcare settings. This course covers essential topics such as the principles of medical recordkeeping, privacy and security regulations (including HIPAA), electronic health records (EHR) systems, data accuracy, confidential handling of sensitive information, and the legal and ethical considerations involved in managing patient records. Students will learn about the standards for record retention, archiving, and retrieval, as well as the role of medical records professionals in supporting clinical decision-making and healthcare administration. Practical approaches to efficient documentation, coding, and compliance with regulatory requirements are also emphasized, preparing students for key roles in health information management.
Recommended Textbook
Legal and Ethical Aspects of Health Information Management 3rd Edition by Dana C. McWay
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30 Chapters
838 Verified Questions
838 Flashcards
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Page 2
Chapter 1: Workings of the American Legal System
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Sample Questions
Q1) Res judicata is a doctrine that courts are subject to, and it means
A)a matter [already] judged.
B)let the master answer.
C)to let the decision stand.
D)utmost good faith.
Answer: A
Q2) Consideration is an element of contract law that refers to _____.
A)business etiquette
B)exchange from one party in return for performing contractual obligations
C)one party's agreement to a promise
D)an entity's decision to enter into a contract
Answer: B
Q3) A defendant who has been found guilty in a _____ case may appeal the verdict.
A)civil
B)common
C)contract
D)criminal
Answer: D
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3
Chapter 1: Workings of the American Legal System: Part A
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25 Verified Questions
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Sample Questions
Q1) A defendant who has been found guilty in a _____ case may appeal the verdict.
A)civil
B)common
C)contract
D)criminal
Answer: D
Q2) Res judicata is a doctrine that courts are subject to, and it means
A)a matter [already] judged.
B)let the master answer.
C)to let the decision stand.
D)utmost good faith.
Answer: A
Q3) Legislative proposals are called _____.
A)amendments
B)bills
C)ordinances
D)torts
Answer: B
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4
Chapter 2: Court Systems and Legal Procedures
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Sample Questions
Q1) Diversity jurisdiction includes is a form of subject-matter jurisdiction whereby US district courts (e.g., trial courts of general jurisdiction in the federal judiciary) have the power to hear a _____ case where the parties are "diverse" in citizenship, indicating that they are citizens of different states or non-U.S.citizens.
A)civil
B)contract
C)criminal
D)customs
Answer: A
Q2) Diversity jurisdiction is specific to:
A)authority over the question at issue that resulted in a case.
B)citizens of different states as well as the federal courts.
C)general jurisdiction, which does not limit subject matter.
D)state citizens where amounts in controversy are over $75,000.
Answer: B
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Chapter 2: Court Systems and Legal Procedures: Part A
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Sample Questions
Q1) The Federal Rules of Civil Procedure (FRCP) govern all forms of discovery that is performed in federal court; seeking information that is stored electronically in any medium is called _____.
A)court order
B)e-discovery
C)metadata
D)subpoena duces tecum
Q2) Methods of dispute resolution to resolve conflicts and disagreements are called _____.
A)alternative dispute resolution.
B)diversity jurisdiction
C)subject-matter jurisdiction
D)satisfying the judgment
Q3) A counterclaim that is included in a defendant's answer is filed against the _____.
A)court clerk
B)plaintiff
C)third-party defendant
D)zealous witness
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Chapter 3: Judicial Process of Health Information
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Sample Questions
Q1) Which question is asked to establish the trustworthiness requirement as related to the admissibility of the health record into evidence?
A)Did the person recording events (e.g., patient care) have knowledge of the events?
B)Were the health records available at or near time the event was recorded?
C)Were the health records kept during the ordinary course of business?
D)Which external procedures were followed concerning access to health records?
Q2) When information concerning HIV/AIDS, mental health, and substance abuse is released to a third party, a _____ prohibits sharing the information with yet another third party unless the patient signs an authorization to release the information.
A)motion to quash
B)prevention of spoliation
C)redisclosure statement
D)subpoena duces tecum
Q3) A court order is signed by the _____.
A)court clerk
B)defendant's attorney
C)judge
D)plaintiff's attorney
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Chapter 3: Judicial Process of Health Information: Part A
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Sample Questions
Q1) A show cause order _____.
A)authorizes the disclosure of information that would otherwise be prohibited by statute and regulation
B)directs a person or organization to appear in court and explain why the court should not take a proposed action
C)is issued to require a witness to appear in court and/or to present certain documents and other things
D)results in the production of a particular record at trial and requires the records custodian to testify
Q2) A subpoena duces tecum _____.
A)directs a person to appear and explain why the court should not take a proposed action.
B)authorizes disclosure that would otherwise be prohibited by statute and regulation.
C)commands the appearance of a witness to provide testimony during a trial.
D)requires production of a particular record and testimony as to its authenticity.
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Chapter 4: Principles of Liability
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Sample Questions
Q1) Under res ipsa loquitur the _____.
A)condition or injury was not the result of negligence and cannot result in a lawsuit
B)injury could have also occurred without the health care prover's involvement
C)patient could have contributed to his own injury, and a lawsuit is optional
D)provider had exclusive control over the instrument involved in the injury
Q2) Res ipsa loquitur is a type of _____ tort.
A)contractual
B)intentional
C)nonintentional
D)professional
Q3) Which of the following must be demonstrated in order to charge invasion of privacy?
A)An unwarranted exploitation of an individual's personality occurred.
B)A patient's before and after surgical photos were published with his consent.
C)A public report accurately described the negative aspects of a person's activities.
D)A publication was released that described procedures performed.
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Chapter 4: Principles of Liability: Part A
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28 Verified Questions
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Sample Questions
Q1) A physician-patient relationship:
A)applies only to physicians.
B)begins with a patient requesting treatment.
C)commences when the physician undergoes credentialing.
D)starts when the patient becomes ill or injured.
Q2) Which Latin term is associated with a nonintentional tort?
A)Res gestae
B)Res ipsa loquitur
C)Res judicata
D)Respondeat inferior
Q3) Good Samaritan statutes are laws that:
A)establish a time period in which a lawsuit must commence.
B)prohibit governments from being sued without their permission.
C)protect physicians and others from civil liability.
D)shield charitable institutions from liability for torts.
Q4) Nominal damages are awarded:
A)as compensation for an actual loss, including future expenses.
B)for vindication of a right where minimal injury is proven.
C)to punish the defendant by making an example of him/her.
D)when proof of outrageous, malicious or intentional conduct is found.
Page 10
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Chapter 5: Ethical Standards
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Sample Questions
Q1) Autonomy is viewed as a freedom unless it _____.
A)Annoys health providers
B)Causes financial stress
C)Interferes with another's rights
D)Disputes religious beliefs
Q2) In the healthcare context, the distributive justice criterion of contribution refers to the _____.
A)An amount the health insurance provider is expected to reimburse
B)How much money the client pays for the health care service rendered
C)The healthcare provider's write-off amount for the services provided
D)What a person might be expected to contribute to society at a later date
Q3) Justice refers to the obligation to be fair to all people. Comparative justice refers to:
A)Balancing the competing interests of individuals and groups against one another
B)Determining how HMOs should be reimbursed
C)Creating a staffing formula or acuity scale to determine the nurse-patient ratio
D)Selecting how Medicaid benefits should be provided
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Chapter 5: Ethical Standards: Part A
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Q1) Which is the equal opportunity to receive resources that requires the authority to provide the service due to others?
A)comparative justice
B)distributive justice
C)justice
D)morality
Q2) Consequentialism is also known as _____.
A)deontology
B)justice
C)privacy
D)utilitarianism
Q3) The obligation to be fair to all people is considered _____.
A)fidelity
B)justice
C)morals
D)values
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Page 12
Chapter 6: Ethical Decisions and Challenges
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Sample Questions
Q1) Insurance companies may cause an ethical dilemma by requiring _____.
A)adherence with Medicare coding practices
B)limitations of inpatient hospitalization stays
C)primary care referrals to a healthcare specialist
D)use and distribution of just formulary medications
Q2) In the context of ethics, the belittling or criticizing of skills, knowledge or qualifications of another professional is referred to as _____.
A)Defamation
B)Disparagement
C)Libel
D)Slander
Q3) Which would create an ethical concern?
A)Altering statistics to meet accreditation requirements.
B)Documenting late entries as such in a patient's record.
C)Revealing conflicts of interests to hospital administration
D)Televising press conferences at the health care facility.
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Chapter 6: Ethical Decisions and Challenges: Part A
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Sample Questions
Q1) When peoples serve as a role models, they set a good example for others to follow and accept responsibility for mistakes; the behavior is considered _____ because the manager does not have to interact with staff to be a role model.
A)actual
B)disparaging
C)passive
D)statutory
Q2) Which is the group formed within an organization or profession to evaluate current guidelines and establish new guidelines?
A)Credentials committee
B)Ethics committee
C)Patient rights committee
D)Safety committee
Q3) Which is an internal ethical challenge for the health information department of a health care facilities?
A)Discharging patients too soon
B)Information privacy and security
C)Life-support issues
D)Substance abuse
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Page 14
Chapter 7: Bioethical Issues
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Sample Questions
Q1) Prenatal testing can cause _____.
A)Defective genes
B)Genetic abnormalities
C)Risk to the fetus
D)The control of hereditary factors
Q2) The use of an organ or body part from another human (donor) is called an _____.
A)Allograft
B)Autograft
C)Heterograft
D)Xenograft
Q3) Euthanasia is the act or practice of causing death painlessly, with the aim to end suffering.Which act is associated with passive euthanasia?
A)DNR order
B)Initiating the dying process
C)Withdrawing treatment
D)Withholding treatment
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Chapter 7: Bioethical Issues: Part A
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Sample Questions
Q1) What refers to the termination of a pregnancy before the viability of the fetus?
A)abortion
B)eugenics
C)genetic screening
D)perinatal testing
Q2) Which patient right is associated with the issue of HIV/AIDS?
A)Confidentiality
B)Duty to treat
C)Genetic testing
D)Prenatal surgery
Q3) Two types of advance directives include a living will and a(n) _____ for health care.
A)durable power of attorney
B)euthanasia directive
C)PSDA
D)Uniform Act
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16
Chapter 8: Patient Record Requirements
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Sample Questions
Q1) Institutional standards of care _____.
A)Are enforceable by federal and state law
B)Can be lower than state and federal regulations
C)Do not carry the force of law
D)Have no bearing on establishing negligence
Q2) If an item was not charted in a health record, it is presumed that _____.
A)If it wasn't documented, it wasn't done
B)It was not necessary to document that item
C)Providers can be excused for being too busy delivering care to document
D)When an order is written, it was carried out even if not documented as such
Q3) When an incorrect entry is documented in the electronic health record (EHR), the responsible provider documents the correction as an addendum in a new document and a(n) _____ links the original document (that contains the incorrect entry) to the addendum.
A)Computer code
B)E-signature
C)Nursing entry
D)Physician order
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Chapter 8: Patient Record Requirements: Part A
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Sample Questions
Q1) Which is a statutory source that governs the content requirements for health records?
A)Health Insurance Portability & Accountability Act
B)Joint Commission accreditation standards
C)Medical staff bylaws, rules and regulations
D)State codes, rules and regulations
Q2) Which is an institutional source that governs the content requirements for health records?
A)American Osteopathic Association standards
B)Medical staff bylaws, rules and regulations
C)Medicare Conditions of Participation
D)State codes, rules and regulations
Q3) Which is an example of personal information associated with the health record?
A)Alcohol, tobacco, and work history
B)Demographic data, such as address
C)Test results and operative reports
D)Third-party payer information
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18
Chapter 9: Confidentiality and Informed Consent
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Sample Questions
Q1) Implied or tacit consent applies to _____.
A)Emergency situations involving a conscious adult
B)Good Samaritan elective procedures and treatment
C)Invasive procedures that require general anesthesia
D)Procedures involving little or no risk to the patient
Q2) Which legislation was enacted to allow patients to create advance directives while competent.
A)FOIA
B)HIPAA
C)PSDA
D)TEFRA
Q3) A constitutional basis for the right to privacy exists because _____.
A)HIPAA legislation outlines patients' right to privacy
B)Individual states have ratified state constitutions to this effect
C)Privacy is explicitly stated as a right in the United States Constitution
D)The Supreme Court has applied privacy in the context of health information
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Chapter 9: Confidentiality and Informed Consent: Part A
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Q1) Confidentiality and privacy are sometimes used interchangeably, and they have _____ meanings.
A)common law
B)identical
C)separate
D)similar
Q2) Good Samaritan laws were created by some state legislatures to protect ____ from liability for unauthorized treatment when a delay in treatment would result in death or serious harm.
A)citizens
B)governments
C)patients
D)providers
Q3) Which is permitted to sign a document that grants informed consent to treatment?
A)competent patient
B)legally incompetent adult
C)minor under the age of majority
D)minor who is not pregnant
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Chapter 10: Access to Health Information
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Sample Questions
Q1) Which is categorized as a business associate, as defined by HIPAA regulations?
A)Government entities
B)Health care providers
C)Patients and family members
D)Third-party payers
Q2) Which is a HIPAA Privacy Rule exceptions to the requirement that consent to release protected health information (PHI) be obtained prior to disclosure?
A)Adverse events involving provider negligence
B)Contained accidental chemical exposure
C)Instances concerning victims of abuse or neglect
D)Non-violent trauma that results in emergency care
Q3) Third parties are required to obtain the patient's permission when _____ wish to access the patient's protected health information.
A)Children of elderly parents
B)Accrediting and licensing agents
C)Health care facility's legal attorneys
D)Medicare and Medicaid payers
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Chapter 10: Access to Health Information: Part A
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Sample Questions
Q1) Patients have an opportunity to consent, reject, or restrict the use of their personal health information, which is done by providing a _____ to the patient
A)minimum necessity standard
B)notice of privacy practice
C)preemption doctrine
D)release of information authorization
Q2) HIPAA requires the patient to consent to the use and disclosure of health information for treatment, payment, or health care operations (TPO).Which statement associated with the TPO regulation is true?
A)Covered entities are mandated by HIPAA to obtain patient consent prior to starting any patient care or treatment.
B)Patients can consent to the use of their information, but they are not permitted to reject the use of their information.
C)Third-party payers cannot require that enrollment in a health plan is contingent upon obtaining the patient's consent.
D)Upon patient request, covered entities must provide a list of all disclosures of the patient's information.
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Chapter 11: Specialized Patient Records
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Sample Questions
Q1) Accrediting standards _____.
A)Are enforceable by law, regardless of whether federal or state in origin
B)Demonstrate that a facility needs to improve treatment provision and staff
C)Have no bearing on malpractice or negligence actions brought by patients
D)May be used in establishing a standard of care during a negligence action
Q2) The disclosure of mental health records to _____ may be made without express patient authorization.
A)Attorneys requesting information through discovery
B)Clergy and representatives of the patient's church
C)Family members of the mental healthcare patient
D)Treating healthcare personnel within the facility
Q3) A system that assigns a unique identifier, such as a number or coding system, to an individual who undergoes HIV testing is called _____ testing
A)Anonymous
B)Mandatory
C)Optional
D)Regulatory
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Chapter 11: Specialized Patient Records: Part A
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Sample Questions
Q1) Accreditation standards and professional guidelines _____.
A)are used to establish mandates of care
B)do not have the same force as statutes
C)might be less specific than Medicare CoP
D)were developed by departments of health
Q2) If a drug or alcohol abuse patient is being treated for trauma that is not related to the abuse, the patient is not typically located in the _____ area of the health care facility.
A)drug or alcohol treatment
B)emergency department
C)intensive care unit
D)nursing station
Q3) Facilities that house specialized patient records generally require _____ confidentiality requirements as compared with acute care settings.
A)equal
B)less
C)stricter
D)the same
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24
Chapter 12: Risk Management, Quality Management, and Utilization Management
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Sample Questions
Q1) Which is an obstacle to peer review activities?
A)Administrative feedback and input
B)Fear of reprisals for candid criticism
C)Participation by healthcare providers
D)Resultant measures to improve care
Q2) The Darling vs.Charleston Community Memorial Hospital case established the precedent that _____.
A)Abolished the doctrine of charitable immunity
B)Hospitals are not liable for provider malpractice
C)Medicaid patients cannot file negligence lawsuits
D)Profit hospitals only are liable for employee negligence
Q3) Which an investigation into a serious event, including clinical and administrative review?
A)Discovery process
B)Incident reporting
C)Root-cause analysis
D)TPO procedures
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Page 25
Chapter 12:
Risk Management, Quality Management, and Utilization Management: Part A
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Sample Questions
Q1) Information about disciplinary actions is reported to the _____ by hospitals, medical societies, licensing boards, prepaid medical practices, and other health care entities.
A)Healthcare Integrity and Protection Data Bank
B)Medical Information Bureau
C)National Practitioner Data Bank
D)Quality Improvement Organizations
Q2) A properly documented patient record will _____ the health care facility's risks.
A)augment
B)heighten
C)increase
D)reduce
Q3) Which force influences the growth of risk management?
A)Decreased medical malpractice lawsuits resulted in high damage awards.
B)Implementation of the doctrine of charitable immunity via court decisions.
C)Joint Commission required hospitals to implement risk management programs.
D)State legislatures established no requirements for risk management programs.
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Page 26
Chapter 13: Information Systems
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Sample Questions
Q1) E-health practices _____.
A)Are subject to the same requirements for safeguarding confidentiality of PHI
B)Have been assigned exempt status from HIPAA regulations and requirements
C)Govern only those patients who receive Medicare reimbursable services
D)May be implemented by entities subject to Medicare Conditions of Participation
Q2) Under HIPAA security rules, required specifications _____.
A)Are optional for certain types of facilities
B)Help in detecting security violations
C)Must be implemented by all facilities
D)Provide opportunities to ignore certain rules
Q3) Permissions granted in an electronic health record system involve _____.
A)Authenticating individual entries made in the EHR
B)Ensuring that people are who they say that they are
C)Levels of access granted to an operating system
D)Preventing malicious attempts to destroy health data
Q4) An advantage of switching to electronic health records is _____.
A)Decreased accessibility of information
B)Establishment of data mining procedures
C)Illegibility of information in the patient record
D)Reduced capacity for information storage
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Chapter 13: Information Systems: Part A
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Sample Questions
Q1) Release of information (ROI) requests are traditionally filed in the paper-based patient record, and when a subpoena duces tecum or court order is processed by the HIM department the ROI request documents located in the record are _____.
A)excluded if the judge didn't sign the legal documents
B)included when photocopying the patient record
C)messengered to the court with the original record
D)removed from the record before photocopying
Q2) Which is an example of physical security associated with the electronic health record (EHR)?
A)background checks on employees
B)establishing levels of access
C)power surges or spikes
D)sabotage prevention
Q3) The careless handling of patient information house in an electronic health record (EHR) creates concern about _____.
A)accreditation standards
B)professional codes of ethics
C)security safeguards
D)unauthorized expenditures
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Chapter 14: Health-Care Fraud and Abuse
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Sample Questions
Q1) A qui tam action is defined as _____.
A)Any action brought against a healthcare facility or provider by a third-party payer or third-party administrator
B)Government entity that sue on behalf of a private plaintiff to receive a portion of the recovered funds
C)Private plaintiffs who sue on behalf of the U.S.government and who receive a portion of the recovered funds
D)The prosecution of fraud and abuse, which results in governments receiving a portion of recovered funds
Q2) Anti-kickback statutes were enacted to prevent _____.
A)HMO control of health care
B)Overbilling of laboratory services
C)Plaintiffs from filing qui tam actions
D)Remuneration for patient referrals
Q3) Which usually involves a qui tam action?
A)FCA claim
B)HIPAA violation
C)Negligent action
D)Stark laws
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Chapter 14: Health-Care Fraud and Abuse: Part A
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Q1) Federal and state government health programs and third-party payers lose _____ of dollars annually due to intentional fraudulent actions and poor coding practices.
A)billions
B)millions
C)thousands
D)trillions
Q2) Match the type of facility or service with the appropriate law. Occupational and physical therapy practices
A)Stark I
B)Stark II
Q3) Match the law enforcement agency that fights fraud and abuse with its purpose. Its DCIS branch investigates fraud schemes committed against the military's health insurance.
A)Federal Bureau of Investigation
B)Office of Inspector General
C)State Attorney General
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Chapter 15: Law and Ethics in the Workplace
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Q1) Incorporating ethics into an employee's performance evaluation _____.
A)Encourages the employee to treat others with respect
B)Has little bearing on employee performance
C)Is not appropriate and is, in fact, illegal
D)May adversely affect corporate compliance
Q2) Substance abuse in the workplace _____.
A)Impacts only the person who is the substance abuser
B)Is only a problem with regard to performance impairment
C)May contribute to illegal behavior to support the habit
D)Must be addressed by terminating the employee
Q3) Which legislation requires employers to verify the identity of employees prior to hiring them?
A)Employment Eligibility Verification Act
B)Homeland Security Act
C)Immigration Reform and Control Act
D)Social Security Act
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Chapter
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Q1) Match the type of employee with its definition. Someone designated by laws as being subject to tax withholding requirements imposed on employers but who otherwise is not an employee.
A)Independent contractor
B)Leased employee
C)Regular employee
D)Statutory employee
Q2) Match the type of employee with its definition. Individuals who agree to perform certain work according to their own means, manner, and methods of performance
A)Independent contractor
B)Leased employee
C)Regular employee
D)Statutory employee
Q3) Which assists the worker or the worker's family in replacing income and provides compensation for medical expenses if there is an injury, illness, or death occurring on the job?
A)Unemployment insurance
B)Workers' compensation
To view all questions and flashcards with answers, click on the resource link above. Page 32