HIT Exam 3 Questions with Correct Answers Latest Update 2025-2026
certificate of destruction - Answers the document that is permanent evidence showing what
data and records were destroyed, who destroyed such records, and the method of destruction
author - Answers when a nurse writes a verbal order from a physician on the physician order
sheet in the health record, the nurse is the _____ of the entry
legal health record - Answers the business record generated at or by the healthcare provider or
organizations that addresses the patient's episode of care
ECRM - Answers this process has been developed to combat increased costs associated with
the legal discovery of the EHR
computer code - Answers when an incorrect entry is documented in the EHR, the responsible
provider documents the correction as an addendum in a new document and a _____ links the
original document that contains the incorrect information to the addendum
record return schedule - Answers a document that details what data will be retained, the
retention period, and the manner in which the data will be stored
statute of limitations - Answers Conditions of Participation in the Medicare program require
hospitals to maintain health records for the period of the state's applicable
case trustee - Answers when a healthcare facility files a bankruptcy and closes, a ____ is
appointed to make decisions for the bankrupt healthcare provider
institutional standards - Answers of care do not carry the force of law
business records - Answers the health record is defined as the ______ generated at or by the
healthcare provider or organization, which documents treatments and services delivered during
the patient's episode of care by the provider or organization
rubber stamp signature - Answers the use of ______ to authenticate health record entries has
been eliminated by CMS
authentication - Answers confirms the content of the entry, either by written signature, initials, or
computer-generated signature code
deeming authority - Answers the Joint Commission, AOA HFAP, and DNV have been granted
______ by CMS as substitutions for compliance with the Medicare Conditions of Participation
privacy rule - Answers the HIPAA ____ grants rights to patient to amend their health record
draw single line through the entry and write "error" next to it, along with the date, time, and
initials of the person making the correction. the line should be drawn so that whatever was
written can be read - Answers describe the process for making a correction to a paper-based
, record
implied consent - Answers or tacit consent applies to procedures involving little or no risk to the
patient
privacy; confidentiality - Answers refers to be left alone; is the obligation of a healthcare provider
to prevent dissemination of patient information
physician-patient privilege - Answers applies to information obtained in the context of
introduction of evidence at trial
Federal Privacy Act - Answers allows a patient greater access to records than is provided for by
HIPAA
living will - Answers provides direction about what medical care is to be provided in the event of
incapability or inability to make decisions
implied consent - Answers would be the basis for a surgeon to repair a ruptured spleen of a
child in the absence of a parent/guardian
Freedom of Information Act - Answers applies to governmental record-keeping
Good Samaritan - Answers laws provide legal protection for unauthorized treatment
emancipated - Answers a 17 year-old who enters the armed forces is an example of an _____
minor
informed consent - Answers requires that consent must be received from a competent adult for
it to be valid
HIV - Answers confidentiality of _____ information allows a positive test result to be disclosed
without prior consent to protect the public if actions are taken to protect the patient's identity
admission date - Answers is considered an identifier of PHI
Nationwide Privacy & Security Framework for Electronic Exchange - Answers issued by the U.S.
Department of Health and Human Services addresses privacy and security challenges related to
these exchanges
de-identified - Answers patient information that is stripped of all identifiers is referred to as
_______ health information
substituted consent - Answers the legal doctrine that allows an authorized person to consent to
or forgo treatment on the patient's behalf when the patient is not legally competent to provide
consent is known as
Notice of Privacy Practice - Answers the HIPAA privacy rule requires healthcare providers to
certificate of destruction - Answers the document that is permanent evidence showing what
data and records were destroyed, who destroyed such records, and the method of destruction
author - Answers when a nurse writes a verbal order from a physician on the physician order
sheet in the health record, the nurse is the _____ of the entry
legal health record - Answers the business record generated at or by the healthcare provider or
organizations that addresses the patient's episode of care
ECRM - Answers this process has been developed to combat increased costs associated with
the legal discovery of the EHR
computer code - Answers when an incorrect entry is documented in the EHR, the responsible
provider documents the correction as an addendum in a new document and a _____ links the
original document that contains the incorrect information to the addendum
record return schedule - Answers a document that details what data will be retained, the
retention period, and the manner in which the data will be stored
statute of limitations - Answers Conditions of Participation in the Medicare program require
hospitals to maintain health records for the period of the state's applicable
case trustee - Answers when a healthcare facility files a bankruptcy and closes, a ____ is
appointed to make decisions for the bankrupt healthcare provider
institutional standards - Answers of care do not carry the force of law
business records - Answers the health record is defined as the ______ generated at or by the
healthcare provider or organization, which documents treatments and services delivered during
the patient's episode of care by the provider or organization
rubber stamp signature - Answers the use of ______ to authenticate health record entries has
been eliminated by CMS
authentication - Answers confirms the content of the entry, either by written signature, initials, or
computer-generated signature code
deeming authority - Answers the Joint Commission, AOA HFAP, and DNV have been granted
______ by CMS as substitutions for compliance with the Medicare Conditions of Participation
privacy rule - Answers the HIPAA ____ grants rights to patient to amend their health record
draw single line through the entry and write "error" next to it, along with the date, time, and
initials of the person making the correction. the line should be drawn so that whatever was
written can be read - Answers describe the process for making a correction to a paper-based
, record
implied consent - Answers or tacit consent applies to procedures involving little or no risk to the
patient
privacy; confidentiality - Answers refers to be left alone; is the obligation of a healthcare provider
to prevent dissemination of patient information
physician-patient privilege - Answers applies to information obtained in the context of
introduction of evidence at trial
Federal Privacy Act - Answers allows a patient greater access to records than is provided for by
HIPAA
living will - Answers provides direction about what medical care is to be provided in the event of
incapability or inability to make decisions
implied consent - Answers would be the basis for a surgeon to repair a ruptured spleen of a
child in the absence of a parent/guardian
Freedom of Information Act - Answers applies to governmental record-keeping
Good Samaritan - Answers laws provide legal protection for unauthorized treatment
emancipated - Answers a 17 year-old who enters the armed forces is an example of an _____
minor
informed consent - Answers requires that consent must be received from a competent adult for
it to be valid
HIV - Answers confidentiality of _____ information allows a positive test result to be disclosed
without prior consent to protect the public if actions are taken to protect the patient's identity
admission date - Answers is considered an identifier of PHI
Nationwide Privacy & Security Framework for Electronic Exchange - Answers issued by the U.S.
Department of Health and Human Services addresses privacy and security challenges related to
these exchanges
de-identified - Answers patient information that is stripped of all identifiers is referred to as
_______ health information
substituted consent - Answers the legal doctrine that allows an authorized person to consent to
or forgo treatment on the patient's behalf when the patient is not legally competent to provide
consent is known as
Notice of Privacy Practice - Answers the HIPAA privacy rule requires healthcare providers to
