CHIMA NCE Data & EHR Questions
An organization's legal health record definition must identify the following regarding individually
identifiable data:
a. Sources
b. Medium
c. Location
d. All of the above - ANS - d
...
CHIMA NCE Data & EHR Questions
An organization's legal health record definition must identify the following regarding individually
identifiable data:
a. Sources
b. Medium
c. Location
d. All of the above - ANS - d
It is best practice to establish a ____ when defining the legal health record.
a. Policy
b. Master patient index
c. Health record matrix
d. Both a and c - ANS - d
The legal health record can only be comprised of documentation that physically exists in an electronic
system.
True/False - ANS - False
Which function is the first step in the creation of a patient's medical record and initiates the flow of
patient information within the EHR?
a. Analysis
b. Patient registration
c. Scheduling
d. Coding - ANS - b
Which of the following processes includes deficiency analysis and chart completion?
a. Release of information
b. Incomplete record
c. Coding
d. Chart reviews - ANS - d
Malpractice cases generally fall into the category of _____.
a. Negligence torts
b. Intentional torts
c. Fraud cases
d. Criminal cases - ANS - a
In a negligence case, a physician will be held to a standard of providing care that reflects what is called
_____ care.
a. Minimal
b. Optimal
c. Maximum
d. Reasonable - ANS - d
A physician who fails to treat a patient who is brought to him or her for care is guilty of _____.
a. Malfeasance
b. Misfeasance
c. Nonfeasance
d. Malpractice - ANS - c
A physician who performs a surgical procedure without patient consent may be prosecuted for _____.
a. Assault
b. Battery
c. Negligence
d. Malfeasance - ANS - b
Defaming another person in writing is called _____.
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