REGULATORY COMPLIANCE

Question 1

additional documentation added to a health record that represents new data not included in the original documentation

Answer 1

ADDENDUM

Question 2

documents that give patients the right to make decisions about their care and designate others to make decisions if they are incapacitated

Answer 2

ADVANCED DIRECTIVES

Question 3

an addition to patient record documentation meant to clarify or further explain and existing record information

Answer 3

AMENDMENT

Question 4

the national organization for medical records professionals

Answer 4

(AHIMA) AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION

Question 5

a computer software program that tracks users by login and documents where in an information system users go and which applications they access

Answer 5

AUDIT TRAILS

Question 6

a legal term; harmful or offensive touching of another

Answer 6

BATTERY

Question 7

a health care administrator charged with overseeing all compliance activities in the facility; often also serves as the privacy officer

Answer 7

COMPLIANCE OFFICER

Question 8

forms patients sign to give permission for treatment

Answer 8

CONSENT FORMS

Question 9

entries in patient health record that correct or change original data

Answer 9

CORRECTIONS

Question 10

the stripping of any identifying pieces of data from health records so they may be used in research, education, or other public health activities

Answer 10

DE-IDENTIFY

Question 11

removing data or information from the health record; this is not permitted

Answer 11

DELETE

Question 12

documentation added to the patient record after the care was provided

Answer 12

LATE ENTRIES

Question 13

the HIPAA standard that requires covered entities to release only the minimum amount of patient health data to meet the need of the request

Answer 13

MINIMUM NECESSARY STANDARD

Question 14

implemented by the Joint Commission in 2002, these goals focus on practices to safeguard patients in the health care delivery system; one example is the universal protocol, which requires a time out before any surgical procedure to verify if right patient, right side, right procedure, etc

Answer 14

NATIONAL PATIENT SAFETY GOALS

Question 15

a unique set of characters, letters, and numbers that is kept private and allows users with an appropriate login ID to access an information system

Answer 15

PASSWORD

Question 16

the legislation that gives patients the right to make decisions about their care and outcomes, including being left alone to die and not resuscitated if that is not their desire

Answer 16

(PSDA) PATIENT SELF-DETERMINATION ACT

Question 17

HIPAA-required individual who is the point person for any privacy concerns or complaints; leads the facility in communicating privacy practices and reviewing existing practices for compliance with privacy requirements

Answer 17

PRIVACY OFFICIAL

Question 18

duplication; generally refers to data

Answer 18

REDUNDANCY