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Exam Code: AHIMA-CHPS
Exam Name: Certified in Healthcare Privacy and Security (CHPS)
Number of questions: 150 total questions (125 scored + 25 pretest items)
Time allotted: 3 hours, 25 minutes of test time (total appointment time 3 hours, 30 minutes including memorizing the agreement)
Passing score: 300 (on the AHIMA standardized scale)


- Ethical, Legal, and Regulatory Issues/ Environmental Assessment
- Identify responsibilities as a privacy officer and/or security officer
- Serve as a resource (provide guidance) to your organization regarding privacy and security laws,regulations, and standards of accreditation agencies to help interpret and apply the standards
- Apply preemption principles to ensure compliance with state regulations that are applicable to privacy
- Evaluate the privacy and security policies related to health information exchanges
- Demonstrate privacy and security compliance with documentation, production and retention as requiredby State and Federal law as well as accrediting agencies
- Analyze the impact of access to protected health information (PHI) during a public health emergency

– Privacy and Security Program Management and Administration
- Manage the distribution process of the organizations Notice of Privacy Practices
- Manage the process for requests for patients rights as outlined in the Notice of Privacy Practices (e.g.,restrictions, amendments, etc.)
- Manage contracts and business associate relationships and secure appropriate agreements related toprivacy and security (e.g., business associate agreement [BAA], service level agreement [SLA], etc.)
- Evaluate and monitor the facility security plan to safeguard unauthorized physical access to information,and to prevent theft or tampering
- Establish a preventative program to detect and prevent privacy/security breaches
- Develop, deliver, evaluate, and document training and awareness on information privacy and security toprovide an informed workforce
- Educate workforce members on the changes to organizational policies, procedures, and practices relatedto privacy and security
- Collaborate with appropriate organization officials to verify that information used or disclosed for researchpurposes complies with organizational policies and procedures and applicable privacy regulations
- Manage appropriate de-identification processes
- Assess and communicate risks and ramifications of privacy and security incidents to a designatedorganizational leadership, including those by business associates
- Verify that requesters of protected information are authorized and permitted access to the protectedhealth information (PHI)
- Apply the “minimum necessary” standard when creating, documenting, and communicating protectedhealth information (PHI)
- Define HIPAA-designated record sets for the organization in order to appropriately respond to a request forrelease of protected health information (PHI)
- Identify information and record sets requiring special privacy protections
- Manage disclosures for marketing and fundraising related to protected health information (PHI)

- Information Technology/Physical and Technical Safeguards
- Develop and manage an organizations information security plan, taking into consideration 45 CFR 164.306
- Manage policies, procedures, and rules to protect the integrity, availability, and confidentiality ofcommunication of health information across networks
- Ensure reasonable safeguards to reduce incidental disclosures and prevent privacy breaches
- Collaborate in the development of a business continuity plan for planned downtime and contingency planning for emergencies and disaster recovery
- Evaluate, select, and implement information privacy and security solutions
- Monitor compliance with the security policies and ensure compliance with technical, physical, and administrative safeguards
- Assess the risk to and criticalities of new information systems which contain protected health information (PHI)
- Assess and monitor physical security mechanisms to limit the access of unauthorized personnel to facilities, equipment, and information
- Assess and monitor technical security mechanisms to control access and protect electronic protected health information (PHI)
- Perform ongoing risk assessments for existing information systems which contain protected health information (PHI)
- Ensure appropriate technologies are used to protect information received from or transmitted to external users
- Manage the process for verifying and controlling access authorizations, authentication mechanisms, and privileges including emergency access
- Identify event triggers for abnormal conditions within a network system (e.g., intrusion detection, denial of service, and invalid log-on attempts)
- Manage the media control practices that govern the receipt, removal, re-use, or disposal (internal and external destruction) of any media or devices containing sensitive data
- Develop and maintain the inventory of software, hardware, and all data to protect information assets and to facilitate risk analysis

- Investigation, Compliance, and Enforcement
- Monitor and assess compliance with state and federal laws and regulations on a routine basis related to privacy and security to update organizational practices, policies, procedures, and training of workforce
- Develop policy and procedure for breach notification
- Establish an incident/complaint investigation process, and develop a response plan to mitigate a privacy or security incident
- Ensure workforce is knowledgeable on how to report a potential privacy or security incident
- Enforce privacy and security policies, procedures, and guidelines to facilitate compliance with federal, state, and other regulatory or accrediting bodies
- Monitor and audit access to protected health information (PHI)
- Perform risk assessment for breach notification
- Coordinate the organizations response to inquiries and investigations from external entities relating to privacy and security to provide response consistent with organizational policies and procedures within the required timeframe
- Notify appropriate individuals/agencies/media within time frame for breach notification
- Maintain the appropriate documentation for breach notification