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Question 1 reset

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A patient requests an amendment to their medical record, stating that a diagnosis is incorrect. As the privacy officer, what is your FIRST step?

Forward the request directly to the attending physician

Deny the request immediately as the record is legal documentation

Provide the patient with the facility's amendment policy and process

Update the record based on the patient's statement

Question 2 reset

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Your organization is implementing a new electronic health record (EHR) system. Which of the following is a CRITICAL privacy and security consideration during the implementation phase?

Ensuring all staff members have immediate access to all patient data

Establishing appropriate access controls based on roles and responsibilities

Skipping security risk assessments to expedite the rollout

Using default passwords for all user accounts initially

Question 3 reset

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A business associate experiences a significant data breach involving your organization's PHI. According to HIPAA, which of the following actions is your organization PRIMARILY responsible for?

Directly notifying all affected individuals

Conducting the forensic investigation of the breach

Ensuring the business associate provides notification to individuals and HHS

Paying for credit monitoring services for affected individuals

Question 4 reset

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A researcher requests access to a large dataset of de-identified patient information for a study. What is the MOST important factor to verify BEFORE granting access?

The researcher's affiliation with a reputable institution

The researcher's agreement to publish the findings

That the data has been properly de-identified according to the HIPAA Privacy Rule standards

The researcher's willingness to sign a confidentiality agreement

Question 5 reset

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An employee in the billing department routinely accesses the medical records of their neighbors who are patients at your facility, even when it's not related to their job duties. What type of violation is this?

Security incident

Privacy breach

Permitted disclosure

Minimum necessary violation

Question 6 reset

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Your organization's Notice of Privacy Practices (NPP) must be provided to patients:

Only upon their first visit

Annually

At the time of the first service delivery after the NPP is updated

Only if the patient specifically requests it

Question 7 reset

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A patient requests a restriction on the disclosure of their PHI for treatment purposes, stating they have paid for the service entirely out-of-pocket. Under HIPAA, is your organization required to honor this request?

No, restrictions on treatment disclosures are not permitted

Yes, the organization must honor the restriction

Only if the restriction is deemed reasonable by the provider

Only if the patient provides a written explanation for the restriction

Question 8 reset

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Your organization is conducting a risk assessment. Which of the following BEST describes a vulnerability?

A potential threat to the confidentiality, integrity, or availability of PHI

A weakness in a system or process that could be exploited by a threat

An event that results in the unauthorized access, use, or disclosure of PHI

The likelihood and impact of a potential threat exploiting a vulnerability

Question 9 reset

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Which of the following is a key element that MUST be included in a Business Associate Agreement (BAA)?

A guarantee of zero security breaches

The specific permitted uses and disclosures of PHI by the business associate

The business associate's agreement to provide treatment to patients

A clause stating the business associate owns the patient data

Question 10 reset

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Your organization experiences a ransomware attack that encrypts patient data. What is the FIRST step in your incident response plan?

Immediately pay the ransom to regain access to the data

Contact law enforcement

Activate the business continuity and disaster recovery plan

Notify all affected patients

Question 11 reset

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An employee receives a phishing email that asks for their login credentials to access the EHR. They enter their username and password. What type of security event is this?

Data breach

Insider threat

Social engineering attack

Malware infection

Question 12 reset

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Your organization is considering using a cloud-based service for storing electronic PHI. What is a CRITICAL step in ensuring HIPAA compliance?

Obtaining a general statement of compliance from the cloud provider

Entering into a Business Associate Agreement (BAA) with the cloud provider

Ensuring the cloud provider is located within the same state

Requiring all data to be encrypted at the application level only

Question 13 reset

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According to HIPAA, what is the MINIMUM necessary standard?

Disclosing the minimum amount of information required for treatment, payment, or healthcare operations

Disclosing the absolute minimum amount of PHI under any circumstance

Limiting access to PHI to only those employees with direct patient care responsibilities

Ensuring that all disclosures of PHI are made in a secure manner

Question 14 reset

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A patient requests access to their psychotherapy notes. According to HIPAA, is your organization required to provide this access?

Yes, patients have a right to access all their health information

No, psychotherapy notes have special protections under HIPAA

Only if the patient's therapist provides written consent

Only if the notes are needed for legal proceedings

Question 15 reset

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Your organization is implementing a new policy regarding the use of personal mobile devices for accessing company email, which may contain some PHI. What is a KEY security consideration for this policy?

Allowing unrestricted access to email on all personal devices

Requiring strong passwords and encryption on all devices

Discouraging the use of personal devices altogether

Providing a stipend for employees to purchase secure devices

Question 16 reset

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During a public health emergency, a local health department requests access to a list of all patients diagnosed with a specific infectious disease. What HIPAA provision allows for this disclosure?

Treatment

Payment

Healthcare Operations

Public Health Activities

Question 17 reset

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Your organization is conducting routine audits of access logs. What is the PRIMARY purpose of these audits?

To track employee productivity

To identify potential security breaches or inappropriate access to PHI

To ensure the EHR system is functioning correctly

To generate reports for administrative purposes

Question 18 reset

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A patient believes their privacy rights have been violated and wants to file a complaint. To whom can they file a complaint?

Only to your organization's privacy officer

Only to the Office for Civil Rights (OCR)

To both your organization and the Office for Civil Rights (OCR)

Only to their state's medical board

Question 19 reset

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Your organization is disposing of old computer hard drives that contain unencrypted PHI. What is the MOST appropriate method for disposal?

Simply throwing them in the trash

Donating them to a local charity

Physically destroying the hard drives (e.g., shredding, degaussing)

Reformatting the hard drives multiple times

Question 20 reset

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What is the PRIMARY goal of a security awareness training program for your workforce?

To ensure all employees can troubleshoot technical issues

To educate employees on privacy and security policies and procedures

To track employee attendance and participation

To test employees' knowledge of medical terminology

Question 21 reset

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Your organization receives a court order (subpoena) for the medical records of a patient involved in a legal case. What is the FIRST step you should take?

Immediately send the complete medical record

Verify the validity and scope of the court order

Notify the patient before releasing any information

Redact all sensitive information before releasing the record

Question 22 reset

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Which of the following is an example of a physical safeguard under HIPAA?

Implementing password complexity requirements

Conducting regular security risk assessments

Locking server rooms and controlling access

Encrypting data at rest

Question 23 reset

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Your organization is developing a disaster recovery plan. What is a CRITICAL component of this plan related to electronic PHI?

Backing up data regularly and storing it in a secure, offsite location

Training all staff on emergency medical procedures

Having a list of alternative vendors for medical supplies

Ensuring the physical security of the main facility

Question 24 reset

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What is the purpose of an Information Security Plan as required by 45 CFR 164.306?

To outline the organization's financial goals

To document the organization's approach to protecting the confidentiality, integrity, and availability of ePHI

To describe the organization's patient care protocols

To detail the organization's human resources policies

Question 25 reset

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Your organization is implementing a new wireless network for staff use. What is a KEY technical safeguard to consider?

Using the default network name and password

Broadcasting the network name publicly for easy access

Implementing strong encryption (e.g., WPA3) and access controls

Allowing all devices to connect without authentication

Question 26 reset

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An employee reports a lost laptop that contained unencrypted PHI. According to HIPAA's Breach Notification Rule, what is the FIRST step your organization must take?

Immediately notify all affected patients

Conduct a risk assessment to determine the probability of compromise

Report the incident to the local police department

Issue a press release about the lost laptop

Question 27 reset

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What is the PRIMARY purpose of implementing audit trails in an EHR system?

To track the amount of time clinicians spend with patients

To record user activity and access to electronic PHI

To generate billing reports for insurance companies

To monitor the performance of the EHR software

Question 28 reset

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Your organization receives a request from a patient for an accounting of disclosures of their PHI. Which of the following disclosures is generally NOT required to be included in this accounting?

Disclosures for treatment

Disclosures for payment

Disclosures for healthcare operations

Disclosures made pursuant to the patient's written authorization

Question 29 reset

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What is the role of a Security Officer in a healthcare organization?

To oversee patient care and safety

To develop and implement the organization's security policies and procedures

To manage the organization's financial records

To handle patient complaints and grievances

Question 30 reset

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Your organization is considering using email to communicate with patients about their appointments and general health information. What is a CRITICAL privacy consideration?

Using plain text emails for simplicity

Including detailed clinical information in every email

Obtaining the patient's consent for email communication and informing them of the risks

Sending emails only during business hours

Question 31 reset

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During a routine security assessment, a consultant identifies a vulnerability in your organization's firewall. What is the NEXT step you should take?

Immediately replace the firewall

Document the vulnerability and develop a remediation plan

Ignore the vulnerability if there have been no known exploits

Publicly disclose the vulnerability to the vendor

Question 32 reset

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What is the definition of "designated record set" under HIPAA?

Any paper record maintained by the organization

The group of records maintained by or for a covered entity that includes medical records and billing records

Only the electronic medical record system

A list of all patients currently receiving treatment

Question 33 reset

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Your organization is implementing a new policy on Bring Your Own Device (BYOD). What is a key administrative safeguard to include in this policy?

Mandating the use of specific antivirus software

Requiring employees to sign an agreement outlining their responsibilities

Physically inspecting all personal devices before allowing access

Blocking all personal devices from accessing the network

Question 34 reset

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An unauthorized individual gains access to a computer workstation containing patient information because the employee forgot to lock their screen. What type of security incident is this?

Malware infection

Insider threat

Physical security breach

Social engineering attack

Question 35 reset

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Your organization is collaborating with another healthcare entity on a joint research project. What type of agreement is necessary to share PHI for this purpose?

Business Associate Agreement (BAA)

Memorandum of Understanding (MOU)

Data Use Agreement (DUA)

Service Level Agreement (SLA)

Question 36 reset

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What is the timeframe for notifying individuals of a breach of unsecured PHI under HIPAA?

Within 30 calendar days of discovery

Without unreasonable delay, but no later than 60 calendar days from discovery

Immediately upon discovery

Within 90 calendar days of the breach

Question 37 reset

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Your organization's website contains a patient portal. What is a crucial technical safeguard to implement for this portal?

Using simple, easy-to-remember passwords

Allowing unlimited login attempts

Implementing multi-factor authentication

Sharing login credentials with technical support

Question 38 reset

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What is the PRIMARY responsibility of the Privacy Officer in a healthcare organization?

To ensure the physical security of the facility

To manage the organization's financial operations

To develop and implement policies and procedures related to the privacy of PHI

To provide clinical care to patients

Question 39 reset

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Your organization is considering using social media to engage with patients. What is a significant privacy risk to consider?

Patients sharing positive feedback publicly

Employees inadvertently disclosing PHI in posts or responses

The cost of managing the social media accounts

The potential for negative comments about the organization

Question 40 reset

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What is the purpose of a contingency plan in the context of HIPAA security?

To outline procedures for responding to medical emergencies

To establish guidelines for workforce training and education

To ensure the availability of electronic PHI in the event of system disruptions

To describe the process for handling patient complaints

Question 41 reset

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During an investigation into a potential privacy breach, you need to determine which employee accessed a specific patient record at a particular time. Where would you typically find this information?

Employee training records

The organization's phone directory

Audit logs of the EHR system

The facility's visitor sign-in sheet

Question 42 reset

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What is the definition of "integrity" in the context of information security?

Ensuring that information is accessible to authorized users when needed

Protecting information from unauthorized disclosure

Maintaining the accuracy and completeness of information

Preventing the loss of information due to system failures

Question 43 reset

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Your organization is updating its policy on acceptable use of electronic devices. What is a key element to include in this policy?

A list of all approved websites

Guidelines on appropriate use of organizational resources and protection of PHI

Instructions on how to troubleshoot technical issues

A schedule for mandatory device upgrades

Question 44 reset

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An employee discovers a USB drive containing unencrypted patient data in a public area. What should be the FIRST course of action?

Immediately plug the drive into their computer to identify the owner

Report the finding to the security officer or privacy officer

Erase the contents of the drive to protect patient privacy

Attempt to locate the owner themselves

Question 45 reset

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A patient requests a copy of their medical record. According to HIPAA, what is the standard timeframe for providing this copy?

Immediately upon request

Within 15 calendar days of the request

Within 30 calendar days of the request, with a possible 30-day extension

Within 60 calendar days of the request

Question 46 reset

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Your organization is implementing a new email system. What is a fundamental security measure to protect PHI transmitted via email?

Relying on the email provider's default security settings

Prohibiting the transmission of any PHI via email

Implementing encryption for emails containing PHI

Requiring all employees to use personal email accounts for work-related communication

Question 47 reset

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What is the PRIMARY purpose of conducting regular privacy and security risk assessments?

To identify potential threats and vulnerabilities to PHI

To track employee compliance with organizational policies

To measure the performance of the IT department

To prepare for external audits and inspections

Question 48 reset

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Your organization is approached by a marketing firm that wants to send promotional materials to patients with a specific condition. Under HIPAA, what is required before PHI can be used for this purpose?

A Business Associate Agreement (BAA) with the marketing firm

A general notice in the organization's Notice of Privacy Practices

A valid authorization from each patient

Approval from the organization's legal counsel

Question 49 reset

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An employee is terminated for violating the organization's privacy policy. What is a CRITICAL step to take regarding their access to PHI?

Immediately revoke all their access rights to systems and physical locations

Monitor their system activity for one month after termination

Allow them continued access for a transition period

Only revoke access if there is suspicion of malicious intent

Question 50 reset

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What is the definition of "confidentiality" in the context of information security?

Ensuring the accuracy and completeness of information

Protecting information from unauthorized access and disclosure

Guaranteeing that information is available when needed

Maintaining the integrity of data during transmission

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