Answers to Medical Records Lesson 7 Practice Quiz
1. Patient’s name, age, sex, and general condition. Some hospitals may release nature of illness. In federal hospitals only information released is verification of patient’s name and dates of treatment.
2. An order to appear in court or at a deposition with the records specified. No consent is required.
3. Yes, ONLY if medical emergency. Document in the medical record the reason for the release, the date, the type of information released, the name of the person receiving the information, and the name of the person releasing the information.
4. In a federal hospital the only information that may be released without the patient’s consent is verification of the patient’s name and dates of treatment.
5. Yes, A consent from the patient specifying what should be released and to whom.
6. Physician must submit a written request indicating the subject and reason for the study. Once approved by the broad, the Medical Records Department may then begin identifying the patients who fall under the study criteria and retrieving the records. The physician reviews the records, compiles data, and publishes the findings. If the doctor publishes the findings the patient’s names may not be used unless he secures the patient’s written consent.
7. If names are used with the findings a patient’s written consent must be secured. OR the physician can publish the findings with general information used. NO names, addresses, medical record numbers.
8. Can be released to hospital personnel that provide patient care or personnel that need the information to perform their duties. A physician not treating a particular patient is not entitled to access that patient’s medical record.
9. A patient’s written consent prior to the occurrence of the billing audit.
10. Provides access to government records.
11. Patients in federal hospitals may request access to their records. The law specifies the information to be included in the request, including the purpose for which the records will be used. A patient may request an amendment of the medical record. If the physician agrees to the amendment, the amended portion is then sent to all previous requesters of the record. If the physician does not approve the amendment, the patient may submit a statement regarding the information in question. This statement is made a part of the record and is sent with the record when it is released to a requester.
12. Provides regulations regarding the release of confidential medical information. The act states that a written consent for the release of information other than dates of treatment must be secured for the patient.
13. Confidentiality of Alcohol and Drug Abuse Patient Records Regulations (42 Code of Federal Regulations, Chapter 1, Subchapter A, Part 2) Regulations apply to established treatment programs that are federally assisted.
14. No information may be released without the patient’s written consent including acknowledgment of the patient’s presence in the program. The regulations do allow release without patient consent if for child abuse and when the patient has threatened or participated in a crime against program facilities or personnel.
15. The consent must state each element to be released, including the reason for the disclosure and a specified date on which the consent is no longer valid. When releasing information a stamp must be on each set of copies that state the records are being released under federal regulations and may not be further disclosed without another written consent from the patient.
16. A special consent is required to release the information, and instances in which information can be released without patient consent are very specific.
17. Valid Authorization
Alphabetical order
Find Medical Record Numbers
Determine if Requested Records Exist
Put requests in terminal digit order
Pull records
Compare signatures
Copy requested records
Bill for Copies
Mail the requested copies
18. Patient’s name, address, age, sex, and general condition. If the telephone caller requests one of these items, the information can be released while the caller is still on the line. Verification of dates of treatment is acceptable if the patient’s treatment is not for psychiatric conditions or substance abuse. Always best to get name of the requestor, company and telephone number and call back with information. This will ensure that the requestor is legitimate before releasing information.
19. Yes, BUT, Cannot release treatment dates for psychiatric and substance abuse treatments.
20. Take requestor’s name, name of Office, telephone number and the physician’s name. Call back and verify that the requester is, in fact, working for that physician then release information.
21. Only when needed for urgent or emergency patient care.
22. A standard form letter is sent to the requester stating that you need more information, etc.
23. Correspondence Log
24. Made out to the custodian of records with the hospital’s name. Check date for which the custodian is ordered to appear. Check the patient’s name and dates of treatment records being requested are specified. Write down the date, time of service and the person serving the subpoena. Some states require that patients be notified. Ask about a witness fee. Note on the top of subpoena that the fee was asked for.
25. Once the record has been pulled and the authorization verified forward to the copy service. The copy service is held responsible.
26. Check MPI for Medical Record number, Pull the Record, Copy the Record, Complete Affidavit, Prepare envelope, Prepare certified mail documentation, File subpoena.
27. The patient signs consent prior to the blood being drawn.

Test results cannot be released to a third party without a special consent from the patient. Most patients will be counseled in person about the positive HIV.
28. Information pertaining to persons other than the patient should not be released without those persons’ specific consent. Any part of the medical record mentioning another person must be omitted.
29. No information may be released without the patient’s written consent including acknowledgment of the patient’s presence in the program.
30. If the documentation relating to the substance abuse treatment is a minor part of the record, that portion of the record may be omitted from the information released. The court that subpoenaed the record is then told that a portion of the record is being omitted because it is protected by federal law. If the entire record is related to substance abuse the medical record department cannot release the record unless ordered to do so by a judge. The judge will review the record and make a determination about whether or not release of the record under the subpoena would be harmful to the patient.
31. Prior to release of the records the patient sign a special consent form. The general consent form is not acceptable for these types of records.