HAS 104F Air Force Medical Records Management Practice Exam

These questions are part of the practice quiz. Start practicing

• Which agency issues the Temporary Identification Number?
• Which guide provides the steps to set up CHCS record rooms, create pull lists of retirement eligible records, and create the final shipment index?
• Which item is NOT listed on the Medical Document block?
• Which section of Form 2100A corresponds to labs and tests?
• How should sensitive health information be treated and accessed in accordance with privacy policies?
• Which identification number remains constant between CHCS server hosts?
• How do you distinguish between document integrity and authenticity in a medical record?
• Civil penalties under HIPAA can be as low as how much per violation?
• What is the purpose of documentation standards in records management?
• NoPP stands for?
• When records are transmitted to another facility, what method best protects patient privacy?
• What information is never to be released to the public and news media?
• What role does imaging/scanning play in modern AF records management?
• Sequestering a health record is the storage and securing of a medical record separate from other medical records for added security or for legal purposes. Sequestering involves which two actions?
• Medical Record purpose?
• What is the required frequency to review and retire outpatient medical records?
• Where is a Pseudo SSN created?
• Under federal criminal penalties for HIPAA, wrongful disclosure of PHI carries which penalty?
• What is the purpose of including a confidentiality notice in records sent for interfacility transfer?
• A record's lifecycle includes creation, use, maintenance, and what final stage?
• Which statement about ROI logs is true?
• What is a terminal digit roster?
• What is the maximum civil penalty per person per year for HIPAA violations?
• The Privacy Act Statement is associated with which form?
• Which principle under HIPAA and DoD privacy governs disclosures and ensures appropriate scope of PHI sharing?
• The information in the patient's medical record is described as what three qualities and must be safeguarded?
• Which option best represents the four systems used for outpatient record filing?
• Which statement about outpatient records inventories is correct?
• Coordinate an annual review of sequestered records with the Base Legal Office to determine whether the records should continue to be sequestered. With which office should the annual review be coordinated?
• Which items should appear on the Patient Identification block of the medical record?
• What is a terminal digit?
• When do you use pencil?
• Which color is mapped to index 4 in the color list?
• Which of the following is NOT one of the four actions you are involved in when updating an Outpatient Health Record?
• Record reconciliation is best described as?
• The HIPAA privacy rule governs the protection and privacy of what type of information?
• Which statement correctly describes the handling of OB records in terms of special rules?
• Which external accrediting bodies are cited for ambulatory healthcare records standards?
• Describe the proper method to correct an error in a medical record.
• Which step is essential in the ROI (Release of Information) process?
• What is the primary purpose of the Air Force medical record?
• Where should you store the records?
• Which item belongs on the Medical Document block?
• How should a court-ordered disclosure be processed?
• Which term best describes the confidentiality requirement for medical record information?
• Under what circumstances can PHI be disclosed without patient authorization?
• What key privacy laws govern DoD/AF medical records?
• What is a medical record number (MRN) and why is it unique?
• Which statement best describes archival records?
• Information which may affect the patient's morale, character, medical progress or mental health is considered?
• Under the terminal digit color coded and blocked filling system, Medical records are divided into how many sections?
• When should you create a new record folder?
• Which statement correctly differentiates Pseudo SSN and TIN?
• When was HIPAA enacted?
• In the described filing system, what term denotes the method of sorting by digits?
• What will be used as the pull list to retrieve the record eligible for retirement?
• When will service treatment records be retired?
• Which of the following best describes 'completeness' in records management?
• What defines a late entry in a medical record, and how should it be indicated?
• What verification is required before releasing patient information to a requester?
• What form is used to retrieve records from the NPRC that were retired prior to 2003?
• Whose SSN is used to prepare a medical record jacket?
• What governs the retention and destruction timing of records?
• How do standardized style guides impact record entry consistency?
• What is CHCS and how does it relate to AF medical records?
• Why is a retention schedule important for records?
• Which role is primarily responsible for ensuring the record is complete at the point of care?
• Why are date/time stamps and provider credentials critical in chart entries?
• Penalties for HIPAA violations involving commercial gain can be as high as what?
• Which elements are commonly used for indexing scanned records to support retrieval?
• Which document records conclusions, recommendations, actions taken, and after-action results of the review?
• Which statement correctly identifies the two main penalty categories under HIPAA non-compliance?
• All medical records MUST meet the highest possible standards of which three attributes, in addition to the standards established by the Joint Commission & AAAHC?
• Which of the following is true about the Privacy Act Statement and NoPP within the system?
• What is the role of the Privacy Officer in the AF medical records program?
• Which security control is focused on preventing unauthorized access to EHRs?
• Who is responsible for establishing local operating instructions?
• What is the purpose of record auditing in Health Information Management (HIM), and what might an audit examine?
• Which of the following is an example of a privacy breach in medical records?
• Which statement about retirement timing is true?
• Why is an expiration date important on ROI authorizations?
• Outpatient records personnel review records for ______ accuracy?
• What are the essential components of an ROI disclosure entry?
• What is ROI in medical records, and who can authorize disclosures?
• Which standard ensures that a record's content has not been altered after creation?
• Which of the following is NOT listed as a type of medical record?
• What are MTF record managers required to mail?
• What is a loss roster?
• Which color corresponds to index 2 in the color index at the top?
• True or False: Outpatient records inventories are performed for all patients in the MTF?
• Why are maternity OB records treated differently in organization and retention within the medical records system?
• Which of the following is a purpose of HIPAA?
• What are the consequences of inaccurate or incomplete records on patient care and readiness?
• Which HIM performance metrics measure records management effectiveness?
• What is the purpose of the record retirement index file?
• Which of the following best describes a common cause of missing documentation and its prevention?
• In a Problem-Oriented Medical Record (POMR), what is the central organizing feature?
• What is the purpose of audit trails in EHR security?
• Outpatient records are filled by the following filing systems according to the source.
• Poor documentation of vital signs most directly affects which aspect of care?
• What is a Records Custodian responsible for?
• What are the responsibilities of the outpatient records check?
• Which factor best explains why OB records have specialized retention rules?
• In HIM audits, which elements are commonly examined to assess data quality and privacy?
• How long will a member's PCS orders remain in the charge out guide?
• What identifiers are essential to correctly locate a patient’s record in AF systems?
• What information should be captured in an ROI log?
• The Foreign Identification Number begins with which digit?
• What form is used to disclose Medical and Dental Information?
• What is the purpose of vital statistics data in military health records?
• What security controls protect electronic health records in the AF?
• Outpatient records must meet the highest possible standards of _______, _______, _______ and standards of the Joint Commission and the Accreditation Association for Ambulatory Healthcare (AAAHC).
• What is a recommended method to prevent missing documentation in health records?
• Which source provides access to the loss roster?
• When should medical records be returned to the record section?
• TRUE or FALSE? Arrange forms in chronological sequence with the most recent action on top unless otherwise designated.
• What form is used to prepare an outpatient record?
• What steps would you take to reconstruct records after data loss?
• What safeguards accompany destruction of records?
• Which of the following is NOT listed as one of the three primary standards for outpatient records along with Joint Commission and AAAHC accreditation?
• How often does MRRC meet?
• TRUE or FALSE? At least annually the MTF is required to 'retire' or purge outpatient medical records?
• Which steps ensure chart completion prior to discharge?
• A complete medical record will provide which of the following?
• Which statement best reflects ownership of medical records in this context?
• How often will the NCOIC of outpatient records obtain small samples of records to review for quality control purposes?
• Why is proper documentation of vital signs and clinical data important in the chart?
• If an active duty member has not been seen in the last 2 years should their records be retired?
• Which statement best describes a final chart review before discharge?
• What is the primary purpose of a records audit?
• Why is identity verification important for release of information requests?
• Which accrediting body is referenced along with the Joint Commission?
• A copy of the loss roster must be reviewed and signed by the NCOIC of the record section?
• What does the term 'Bundle' mean?
• If a patient is eligible for an SSN but has not reported it to DEERS, which identification number is issued?
• Commanders Designees include?
• MRTR2 stands for?
• What should accompany records sent for interfacility transfer to ensure proper handling?
• What does the acronym CHCS stand for in the DoD/AF medical records context?
• False pretenses to obtain PHI carries which maximum penalty?
• Which practice supports ensuring the quality of scanned documents beyond metadata and storage?
• In accordance with AFIRMS when should a patients medical records become eligible to be retired?
• How does data quality affect patient safety and care outcomes?
• Which term describes Section 3 of Form 2100A?
• Is the signature of the patient on the NoPP mandatory?
• List core elements that must appear in a typical clinical encounter note.
• How should electronic requests for records be validated and fulfilled?
• The DD Form 2005 Privacy Act Statement and the Military Health System NoPP are used to demonstrate what?
• Which items should be included in a patient transfer packet to another facility?
• What factor determines when to retire or destroy a nonactive medical record?
• Which accuracy category addresses the correctness of patient identifiers and demographic information?
• Distinguish between active, inactive, and archival records.
• Regarding the DD Form 2005, Privacy Act Statement and the Military Health System NoPP, which statement is correct?
• The Form 2100A is divided into four sections. Which are they?
• Who reviews the outpatient medical record for accuracy?
• Whose property are medical records?
• What does the Service Treatment Record refer to?
• Which section is primarily responsible for registering patients into CHCS?
• What is a records retention schedule and why is it necessary?
• Who should you consult before discussing official military information with the public?
• What is the primary purpose of the medical records index?
• Name two common record formats used in health information management and describe their structure.
• Which action describes the minimum necessary standard in PHI disclosures?
• Which activity is described as part of the outpatient records check responsibilities?
• Why is HIM staff training essential for compliance and patient safety?
• Where should you return all documents with incomplete patient identification?
• Explain the difference between a 'no-show' entry and an actual clinical encounter in the chart.
• Which statement about a medical record number (MRN) is true?
• Which of the following statements is true regarding HIPAA penalties?
• What document must every patient treated at the MTF be given?
• Who processes all medical, demographic rosters and registers patients into CHCS?
• Which is a key privacy policy requirement?
• Who can authorize decentralization of the numerical file to the patient's family care location?
• Why is indexing of scanned documents critical for retrieval?
• Who is responsible for ensuring all personnel with access to PHI receive HIPAA training?
• Which committee meets quarterly to perform record review functions at the MTF?
• A Pseudo SSN begins with which digit?
• Which of the following is not typically included as a core element of a clinical encounter note?
• Where will the outpatient record manager obtain a loss roster?
• The Temporary Identification Number begins with which digit?
• What is the primary purpose of retention schedules for medical records?
• The process of sequestering a health record is intended for which purposes?
• Which action constitutes a privacy breach that must be reported to the Privacy Officer?
• A bundle for retirement includes which records?
• Which action best preserves record integrity during transit?
• Who is responsible for overall records management in an AF Medical Treatment Facility?
• The loss roster tracks which of the following?
• Define PHI and explain its protection requirements under HIPAA and the Privacy Act.
• Missing records must be added to the ______ until found.
• What does NoPP stand for?
• How should late entries be documented in a military record?
• How are electronic signatures used in Air Force health records and what policies govern them?
• When are inventories completed?
• Which statement best describes Source-Oriented Medical Records (SOMR)?
• Health Care Provider review records for ______ accuracy?