CRIS Clinical Records Information Systems
EXAM COVERAGE
CRIS - Clinical Records Information Systems
Medical Record Ownership - Facility ownership, patient
access rights
Master Patient Index (MPI) - Patient identification and
record tracking
HIPAA Compliance - PHI protection, minimum necessary
rule
Authorizations - Required elements, expiration, purpose of
,disclosure
Release of Information (ROI) - Valid vs invalid requests,
subpoenas vs court orders
Improper Disclosures - Wrong patient release,
unauthorized information, legal risks
Specially Protected Information - HIV, substance abuse,
genetic testing
Legal & Regulatory Requirements - Federal/state privacy
laws, documentation standards
Documentation Standards - Accuracy, completeness,
correction of records
Information Security - Safeguards, access controls,
confidentiality
Record Retention - Retention schedules, destruction
,policies
Audit & Compliance Monitoring - Tracking disclosures,
internal reviews
The tool most often used to gather a complete medical
record is the:
A. Conditions of Admission
B. Notice of Privacy Practices
C. Master Patient Index
D. Information Management Plan
C. Master Patient Index
, The Purpose(s) of the medical record is/are:
A. To assist in further research and education
B. To assist in protecting the legal rights of the patient and
the healthcare facility
C. To provide analysis, study and evaluate care given to
the patient
D. All of the above
Who owns the medical record?
A. The patient
EXAM COVERAGE
CRIS - Clinical Records Information Systems
Medical Record Ownership - Facility ownership, patient
access rights
Master Patient Index (MPI) - Patient identification and
record tracking
HIPAA Compliance - PHI protection, minimum necessary
rule
Authorizations - Required elements, expiration, purpose of
,disclosure
Release of Information (ROI) - Valid vs invalid requests,
subpoenas vs court orders
Improper Disclosures - Wrong patient release,
unauthorized information, legal risks
Specially Protected Information - HIV, substance abuse,
genetic testing
Legal & Regulatory Requirements - Federal/state privacy
laws, documentation standards
Documentation Standards - Accuracy, completeness,
correction of records
Information Security - Safeguards, access controls,
confidentiality
Record Retention - Retention schedules, destruction
,policies
Audit & Compliance Monitoring - Tracking disclosures,
internal reviews
The tool most often used to gather a complete medical
record is the:
A. Conditions of Admission
B. Notice of Privacy Practices
C. Master Patient Index
D. Information Management Plan
C. Master Patient Index
, The Purpose(s) of the medical record is/are:
A. To assist in further research and education
B. To assist in protecting the legal rights of the patient and
the healthcare facility
C. To provide analysis, study and evaluate care given to
the patient
D. All of the above
Who owns the medical record?
A. The patient
