Question

Check Your Understanding 2.2 1. Which of the following statements is false? The legal health record is the portion of the health record that will be disclosed up a. request to parties outside the organization. b. The legal health record can be defined as the unofficial business record used for e dentiary purposes created by or for the healthcare organization. c. The legal health record contains individually identifiable information stored on a medium and collected and directly used in documenting healthcare or health status The legal record includes documentation of healthcare services provided to an in d. vidual during any aspect of healthcare delivery in any type of healthcare organizati as well as the source of the documentation 2. 3. True or False: PHRs are always considered part of the legal health record. What is the definition of derived data? a. Patient-identifiable documentation used for administrative, regulatory, healthca operation, and payment (financial) purposes b. Source data collected and stored in source systems Records created by providers outside of the organization that are received by the org c. nization for patient care d. Factual details aggregated or summarized from a group of health records that provid no means of identifying specific patients 4. True or False: All patient health record entries must be legible and complete, but authenti cation is optional. Which of the following is a code set adopted by HIPAA? a. ICD-9-CM-International Classification of Diseases b. ICD-9-PCS-International Classifications of Procedures c.CDT-Code on Dental Procedures and Nomenclature d. NDC-National Disease Codes 5.

Answer 1

1. B is the false statement as the legal health record is always an official record documenting the patients complete information regarding the problem and treatment given to them by the health care team.

2. True as this is personal health record wereby used in the confidential environment were privacy placy important role but can be used when question of legal comes.

3. a the deriving data includes everything which can bring about the statistical analysis

4. False the records should be complete and legible and the authentication is must.

5. Icd 10 cm and ICD 10 pcs