Below are some CHIMA mock test practice questions! When it comes to health services, one of the most important things one can do is ensure that they have proper documentation of a patient, which comes in handy when looking for one’s medical history. Take the quiz and see how good you are at proper documentation under CHIMA and your role.
Accessibility
Universality
Comprehensiveness
Public Administration
Failure to document the chart at all during a critical time is a breach of standard of care and documentation standards
Correction must be completed by the care provider within 60 days of the request
Both original and revised documentation must be retained as part of the record
Incorrect information should be deleted and replaced with the correct information.
Access whether further consultation is necessary and whether further legal processes may apply if the disclosure is required by law
Verify the identity of the requesting party
Ensure that the written consent form (if any) is filed on the individual’s health record, or that documentation is included providing the date of consent, the information provided and the date of disclosure
Verify that the consent form was dated less than 90 days ago
Entity
Electronic Service Provider
HIE
Health Information Network Provider
Documentation should be true, complete, clear, concise, and legible.
Documentation should include the date and time when the entry was made.
Documentation should be authenticated by the person who prepared it.
Documentation should take place within an hour of the event that is being recorded.
Consultation reports.
Incident reports.
Independent medical examination reports.
Reports to government ministries.
Ask Dr. Brown to provide a consent form from Amy
Provide the records to Dr. Brown only if he is on your medical staff
Provide the records to Dr. Brown since he is treating the patient
Refuse access to the records
Privacy laws.
PIPEDA.
Security laws.
Provincial laws.
Administrative law
Case law
Common law
Statutory law
The mother
The patient
No consent is needed for emergency care
The girlfriend
Remove the incident report and send it to the patient.
Tell the employee to leave the report in the record.
Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record.
Refer this record to the Risk Manager for further review and removal of the incident report.
Invasion of privacy.
Violation of security of person
Slander.
Defamation.
Intellectual property rights
Accountability and governance
Software licensing
Dispute resolution
Accidental
Malicious
Catastrophic
Intentional
Mary is not required to release the extra documentation because the facility has the right to interpret a request and apply the minimum standard rule.
Mary is required to release the extra documentation because the requestor knows what is needed.
Mary is required to release the extra documentation because, in the customer service program for the facility, the customer is always right.
Mary is not required to release the additional information because her administrator agrees with her
1 and 2 only
1 and 3 only
2 and 3 only
2 and 4 only
Electronic signatures are not acceptable in many health care facilities
Evidence cannot be provided that the physician reviewed and approved each report
It is too easy to delegate use of computer passwords
Tampering too often occurs with this method of authentication
Acknowledgement of having received patient’s rights information
Consent to release information
Consent to undergo treatment
Living will
Access control
Destruction process
System inventory
Terminal lock
Shred it.
Try to get it signed, and if not, to document the action taken.
Keep trying to get the document signed until you succeed, even if you must go to the patient's hotline.
File the blank form in the chart.
Risk assessment.
Information system activity review.
Workforce clearance procedure.
Information access management.
TRA
BCP
HIE
PIA
Probation.
Censure.
Expulsion.
Suspension.
How the situation might be averted in the future.
The principles and values at stake.
The facts.
The ethical question.
CHIMA Code of Ethics.
Staff members union.
Human resources department.
Departmental manager.
Wait!
Here's an interesting quiz for you.