CBCS PRACTICE TEST 2022| 150 QUESTIONS| WITH COMPLETE SOLUTIONS
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CBCS
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Liberty University
Documentation Correct Answer: is the record of clinical observations and care a patient receives at a health care facility. Documentation is used to communicate relevant patient info among health care professionals. It also serves as the basis of information conveyed to third party payers who are ...
cbcs practice test 2022| 150 questions| with complete solutions
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CBCS PRACTICE TEST 2022| 150 QUESTIONS| WITH
COMPLETE SOLUTIONS
Documentation Correct Answer: is the record of clinical observations and care a patient receives
at a health care facility. Documentation is used to communicate relevant patient info among
health care professionals. It also serves as the basis of information conveyed to third party payers
who are responsible for reimbursing providers. third party payers include insurance companies,
Medicare, and Medicaid.
Informed Consent Correct Answer: providers explain medical or diagnostic procedures, surgical
interventions, and the benefits and risks involved giving patients an opportunity to ask questions
before medical intervention is provided.
Implied Consent Correct Answer: A patient presents for treatment, such as extending an arm to
allow a venipuncture to be performed. Signature not required.
ARRA American REcovery & Reinvestment Act Correct Answer: in 2009 was signed into law.
A section of the law, the HITECH Act, includes changes to the HIPAA Privacy Rule. This
sections discusses those changes and how they affect documentation procedures.
Protected Health Information PHI Correct Answer: the Privacy Rule has a specific definition for
PHI: individually indentifiable health info transmitted by electronic media, maintained in any
electronic medium, or maintained in any other form or medium. this includes paper forms or
documents verifying conversations. To meet the definition of PHI, the info must be held or
transmitted by a covered entity or a business associates BA.
Covered Entities Correct Answer: are any health plan, clearinghouse or providers. BAs are any
indiv groups or organizations who are not members of the covered entity's workforce that
perform functions or activities on behalf of or for a covered entity. These activities can involve
patient health info.
Individually Identifiable means Correct Answer: Documents that either identify the person or
provide enough info that the person could be identified, Info that includes past, present, or future
physical or mental health conditions, Info that includes provision of health care and info that
includes payment for the provision of health care.
Use Correct Answer: the way PHI is handled internally by a covered entity or its business
associate.
Clearing house Correct Answer: Agency that converts claims into a standardized electronic
format, looks for errors and formats them according to the HIPAA and insurance standards.
Disclosure Correct Answer: Theh way PHI is disseminated from a covered entity or its BA to an
outside person or organization. The Privacy Rule applies to PHI requests by covered entities and
their BAs.
, Minimum Necessary Standard Correct Answer: When disclosing info providers and other
covered entities must limit uses, disclosures and requests to only the amount needed to
accomplish a specific purpose. EX if info is being disclosed for payment purposes, only what is
needed to substantiate a claim should be released.
Notice of Privacy Practices Correct Answer: The legal obligation of providers to explain to
patients how their PHI will be used and disclosed. Notice of privacy practices also must explain
the patient's rights and the covered entity's legal responsibilities with respect to PHI. Providers
who have a direct treatment relationship with an individual must provide this info at the first time
of service, either in the physician's office or at a hospital.
De-identified info. Correct Answer: Info that does not identify an indiv because unique and
personal characteristics have been removed.
How to De-identify Correct Answer: Covered Entity to do one of the following: Strip off certain
elements to ensure that the patient's info is impossible to identify. Have an expert apply generally
accepted statistical and scientific principles and minimize the risk that the info. might be used to
identify an indiv.
Authorizations Correct Answer: The Privacy Rule give the term authorization specific meaning.
Authorization means permission granted by the patient or the patient's representative to release
info for reasons other than Treatment, Payment or health care Operations (TPO). In the past, the
terms consent and authorizations were used interchangeably, but now Consent is used only when
the permission is for Treatment, payment or health care operations TPO
Authorizations are always required for use or disclosure of psychotherapy notes.
Authorization to disclose info applies to the health care facility. It allows the facility to verbally
disclosure or send health info to other organizations Signed authorization which is kept to
document why health info was disclosed..
Authorizations must include the following elements Correct Answer: Specific, meaningful
description of the info to be used or disclosed. the name or other specific identification of the
person or persons or class of persons authorized to make the requested use or disclosure.
To summarize, PHI Correct Answer: may not be used or disclosed by a covered entity unless the
indiv. who is the subject of the info authorizes the use or disclosure in writing. There are two
instances when the Privacy Rule requires use or disclosure without the indiv authorization. 1)
When the indiv or indiv. personal representatative requests access to or an acctng of disclosures
of the PHI2) When the Dept. of health and human Services (HHS) is conducting an
investigations, review or enforcement action.
Under the Privacy Rule, disclosure is permitted without patient authorization under
circumstances such as the following Correct Answer: when patients have the opportunity to
informally agree or object to activities such as to activities such as being in a patient directory or
notifying friends and relatives about their health status. When the public health of the community
is as risk. EX if there is an outbreak of tuberculosis in the community, disclosure is permitted to
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