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172 Cards in this Set

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The commission or omission of an act that a reasonably prudent person would or would not do is

negligence

A legal obligation that requires the actor to conform to a specific standard of care to protect others is:

duty to care

The failure to conform to or the departure from a required duty of care owed to a patient is:

breach of duty

That which describes the conduct that is expected of an individual in a given situation.

standard of care

examples of intentional torts

battery, assault, false imprisonment

In negligence, the execution of an unlawful or improper act is:

malfeasance

Regulations created by federal agencies:

administrative law

A threat coupled with the apparent present ability to do immediate physical harm to another is:

assault

An unconsented touching by one person upon the person of another is:

battery

A person who is physically restrained from leaving a health care facility for not paying a bill is said to be a victim of:

false imprisonment

A complete defense to a defamation act is:

truth

The willful an intentional misrepresentation that could cause harm or loss to a person or property is:

fraud

A wrong, other than breach of contract, which causes harm to another:

tort

A general rule of conduct that is enforced by government is referred to as:

law

The federal agency responsible for administering the Medicare and Medicaid program is the:

CMS

A major function of the executive branch of government is to:

enforce and administer the law

The function of the judicial branch of government is to adjudicate the law. Adjudication means:

resolving disputes in accordance with law

A decision in a case that sets forth a new legal principle establishes a:

precedent

Assault and Battery are:

intentional torts

The concept that no one branch of government is clearly dominant over the other two or a system of checks and balances

separation of powers

Laws that govern the relationships between people are referred to as:

private law

Reasonable anticipation that harm or injury is likely to result from an act or an omission to act:

foreseeability

The body of law that deals with the relationships between private parties and government is referred to as:

public law

Reckless disregard for the safety of another, willful indifference to an injury that could follow an act:

criminal negligence

Failure to act when a duty to act exists:

nonfeasance

The federal department responsible for enforcing the law is:

justice

Wrongfully accusing (in print) someone of committing a crime is:

libel

Peggy Patient was tied to her bed and not fed for two days for failing to pay her telephone bill prior to discharge. She has an action for:

false imprisonment

The written form of defamation is often referred to as:

libel

A physician administers contraindicated (something to be inadvisable while taking particular medication because of a likely adverse reaction
)medicine. This is an example of:

misfeasance

Failure to order needed tests or medication would constitute:

nonfeasance

Bathing a patient in scalding water would constitute:

malfeasance

Dr. Whatchawant diagnoses Peggy Patient with congestive heart failure and sends her on her way because she has no insurance. Peggy Patient could take Dr. Whatchawant to court based on:

breach of duty

In common law, the term referring to that which has been acted on or decided by the courts is:

res judicata

Legal principle that states that judges should attempt to decide cases as similar cases have been decided in the past.

res judicata

A physician who submits multiple bills for single office visits is committing:

fraud

Three branches of government are:

executive, judicial, legislative

A 73 year old male was admitted to the Sunset Nursing facility with senility, cataracts, and s/p cerebrovascular accident with right side hemiplegia. On his second day at the facility, the resident was discovered to have extensive thermal burns on his buttocks and legs by one of the facilities attendants. Which one of the following can the attorney of the resident’s family use as a basis of a lawsuit?

The doctrine of res ipsa loquitur because it allows the plaintiff to shift the burden of proof to the defendant because direct evidence is available.


Torts and contracts are examples of:

private law

Which of the following is not representative of the Elements of Negligence and therefore not necessary to prove for a plaintiff to recover damages?

libel

Which of the following is considered to be an HIM tort?

invasion of privacy

What is the first requirement in establishing negligence?
The plaintiff has to prove the existence of a legal relationship between himself/herself and the defendant.
You are the director of the HIM Department for Bayshore Hosptial. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara’s attorney to provide sworn verbal testimony and/or written answers to questions. Barbara Masters is the _______________ in this case.

plaintiff

You are the director of the HIM Department for Bayshore Hosptial. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara’s attorney to provide sworn verbal testimony and/or written answers to questions.

Bayshore Hospital is the ___________ in this case.

defendant

An offense generally punishable by less than one year in jail and/or fine is:

misdemeanor

A serious crime generally punishable by one or more years of imprisonment in a state or federal penitentiary is:

felony

The formal reading of the accusatory instrument, including the setting of bail is called:

arraignment

The doctrine that decisions of the courts should stand as precedents for future guidance is:

stare decisis

The failure to obtain written consent of the patient before performing a surgical procedure may constitute

battery

The OIG investigates cases of Medicare and Medicaid:

fraud

The definition of Res Ispa Loquitur is:

the things speaks for itself

A dietary aide fails to bring you your liquid diet. You have not been fed in two days. Your blood sugar drops and you slip into a coma. This is an example of a malfeasance.

false

Federal law does not have precedence over state and local laws.

false

What are the guidelines for a HIM professional testifying in court?



Read the record before going to court to be familiar with the information. Read from the medical record only! if asked to testify about treatment, we cannot. We can only read from the medical record.

Upon receipt of a subpoena, review of the chart reveals a diagnosis of drug abuse. What is your next step in complying with the subpoena?



Drug abuse is considered sensitive data and will have to be reviewed by the judge to see if the information is relevant to the case. If it is not, it will be taken out, if it is, it will be allowed.

Name two situations where a minor patient may give consent for their medical treatment.



Substance Abuse, Pregnancy, STDs

Give two examples of "sensitive information" as in regards to a subpoena for medical records.



Substance Abuse, Psychological Issues

Give two examples of what must be disclosed in an informed consent.



Detailed description of what will be happening.


Risks and consequences that could follow.

The doctrine applies to cases in which an employee is lent to another for a particular employment.

borrowed servant

Before the trial, facts are investigated in a process called_________.
This process helps to prevent surprises during the trial.

discovery

Damages that are awarded to compensate for gross negligence and to deter the wrongdoer are known as

punitive damages

The North Carolina court system will only accept “certified” copies of the Medical Record. How may copies be certified?
Attachment of an affidavit

The legal document that demands more detailed information than is provided in a complaint is the:

bill of particulars

A motion that asks a court to rule that there are no facts in dispute and that the rights of the parties can be determined as a mater of law, on the basis of submitted documents, without the need for a trial is:

summary judgement

The person who brings a civil suit seeking damages or other legal relief is the

plaintiff

The legal doctrine that shifts the burden of proof from the plaintiff to the defendant is:

res ispa loquitur

The order that calls for a document to be produced by an organization is called a :

subpoena duces tecum

the sworn statement made by a witness that can be used as evidence in a court is a:

deposition

If an x-ray machine is entered into evidence, it is a form of

demonstrative

That which is used to prove the facts of a case is referred to as

evidence

Knowing that a danger exists and voluntarily accepting the risk by taking a chance and exposing oneself to it is

assumption of risk

The doctrine that holds a physician, for example, responsible for the acts of a nurse in the OR when the physician directs the nurse to perform a particular medical act in the OR and s/he performs it negligently and consequently injures the patient is called

captain of the ship

The doctrine by which the state and federal governments have been immune from liability for harm suffered by the tortuous conduct of employees is

sovereign immunity

evidence based on inference is:

circumstantial

The acts or omissions that may constitute negligence on the part of a nurse often render a hospital liable under the

doctrine of respondeat superior

Laws that limit the period during which legal action may be brought against another party are known as:

statues of limitations

You are the HIM Department director for Bayshore Hospial. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara’s attorney to provide sworn verbal testimony and/or written answers to questions.

Using the case study above, answer the following question:

Barbara Masters is the _________ in this case.

plaintiff

You are the HIM Department director for Bayshore Hospial. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara’s attorney to provide sworn verbal testimony and/or written answers to questions. Using the case study above, answer the following question: The sworn verbal testimony you are asked to provide is called a(n)

deposition

You are the HIM Department director for Bayshore Hospial. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara’s attorney to provide sworn verbal testimony and/or written answers to questions.

Using the case study above, answer the following question:
Referring to the case study, you are involved in what phase of the lawsuit?

discovery

You are the HIM Department director for Bayshore Hospial. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara’s attorney to provide sworn verbal testimony and/or written answers to questions.

Using the case study above, answer the following question:
Bayshore Hospital is the _______ in this case.

defendant

A contractor who agrees to undertake work without being under the direct control or direction of another and is personally responsible for his /her negligent acts.

independent contractor

Comparative Negligence generally requires that damages among multiple defendants be divided:

equally

Which of the below is NOT a preferred defense in a negligence suit

ignorance

Juries decide:

questions of fact

The legal document that demands more detailed information than is provided in a complaint

bill of particulars

In a civil suit, the burden of proving a case lies with the

plaintiff

Evidence furnished by physical things themselves

demonstrative

Consent that requires that a patient have a full understanding of that to which he or she has consented

informed

Consent in cases in which immediate action is required to save an unconscious patient’s life or to prevent permanent impairment of a patient’s health is referred to as

implied

It is preferable that a patient’s consent be procured by the

physician

damages are those damages that are awarded to compensate an individual for the loss of enjoyment of life.

hedonic

damages are those damages that are estimated reparation in money for detriment or injury sustained. Examples may be loss of earnings, medical costs, and loss of financial support.

compensatory

A physician, as an employer of a physician’s assistant, can be held liable for the assistant’s negligence on the basis of respondeat superior.

true

Contracts, particularly those in writing, serve to minimize misunderstandings and offer a means for parties to resolve any disputes that may arise in the course of an undertaking.

true

A contract serves to provide one or more its parties with a non-legal remedy if another of the parties does not perform its obligations pursuant to the terms of the contract.

false

If an estate is probated, who may consent to release medical information for a deceased patient?
the executor of the deceased’s estate

If Mrs. Gray is a legally competent adult, who may have access to her medical record without her express written permission?

her attending physician

If Mrs. Gray is a competent, married 17-year old, who would sign a consent for her surgery?

Mrs. Gray, the patient


Ultimate responsibly for the operation of the health care organization lies with

senior management


Kyle, the HIM Director, has received a request to amend a patient's medical record. The appropriate action for him to take is

route the request to the physician who wrote the note in question.
The hospital provides patient names and addresses to a pharmaceutical company to be used in a mass mailing of free drug samples.

invasion of privacy

HIPAA mandates the creation of a unique identifier code for every patient.

false

What is re-disclosure?



Re-disclosure is the act of obtaining records and then passing them onto another person without written authorization from the patient.

Give an example of an improper re-disclosure of information.

For example, if you get your records from a physician's office and let someone besides yourself look at the records. That is re-disclosure and the physician's office would not be responsible for the other person viewing the record.


Remembering your ROI handout, and the items listed as what is required for a valid authorization, list the items below that determine if an authorization is HIPAA compliant.



Identifying information of the person requesting


Specific information to be requested. Dates of service, what info from them


Name and address of where to be sent.


Notice of the ability to revoke authorization.


Re-disclosure statement.


Time that authorization is valid. ex. 60 days.


Signature and Date


Purpose

A minor who is legally free from parental control is:

emancipated


A written authorization from the patient releasing copies of their medical records is required in which one of the following examples:

the patients attorney


In which of the following cases would the patient’s consent or a court order be required to release medical information?

when the information is alcohol or drug related.



HIPAA requires that certain CE’s provide every patient a Notice of Privacy Practices that set forth all of the following EXCEPT:

CE’s provide every patient with its annual business report

When a person makes a request for his/her records in person, the ROI clerk should _______ in order to establish safeguards for the security and confidentiality of the patient’s information:

ask the requestor for identification and the request in writing

Dr. Knowitall comes to your department to review his neighbors record. Sensing that you are about to refuse him, he interrupts and says, “I am a doctor on staff at this hospital and I have every right to review any record I see fit. Now hand it over!” Your response should be:

you may review the record if you are the attending physician or you have a valid request signed by the patient

As a general rule, a person making a mandatory report in good faith and under statutory command is:

protected from liability claims

The wife of a deceased patient enters the medical record
department to requests her husbands’ records. She brings with her a POA, which was signed two months prior to the patients’ death. The record reveals that the son is shown to be the executor of the estate. You should

Refuse to release records to her since the son is listed as executor of the estate on the chart.

The HIPAA privacy rule covers information in which of the following forms?

oral, electronic, paper

A valid authorization for the disclosure of PHI should not be:

dated prior to discharge

The mother of a physician on your facility’s medical staff was recently admitted to your hospital under the care of another surgeon. The physician now wishes to review his mother’s record.

You can let the physician review his mothers record only with a signed authorization from his mother.

A former patient requests by telephone that a copy of her health record be sent to her new physician in another city.

You obtain an authorization from the patient and then send the information.

A former patient who was treated as an inpatient approximately 2 years ago has filed a lawsuit against your facility. Your facility’s legal counsel has asked to review the patients’ health record.

You do not need an authorization to let him review the records.

Requests for release of information that fall outside of TPO, in most cases information about a patient can only be shared _________________________.

only when the patient authorizes it specifically

One good rule to prevent unauthorized access to computer data is to ________________.

black the screen or turn off the computer when you leave it
If you are sending patient information via e-mail, security is best maintained with __________________.

-password protection at both ends


-encryption if it goes over the internet


-destroying any printouts/place in medical chart

one exception to confidentiality is

a gunshot wound

Facilities will no longer be able to post ____________ anyplace where visitors might see them. This includes door tags and whiteboards at the nurses’ station that are in public view.
patient’s full names
An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implement to minimize the security breach?

access controls

On review of the audit trail from an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case what should the director do?

determine what information was printed and why

To date the HIM department has not charged for copies of records requested by the patient. However, the policy is under review for revision. One HIM committee suggest using the copying fee established by the state. Another committee member feels that HIPAA will not allow for copying fees. What input should the HIM director provide?

base charges on cost of labor and supplies for copying, and postage if mailed.

An individual who brings a lawsuit is called the

plaintiff

Which document directs an individual to bring originals or copies of records to court?

subpoena duces tecum

If the patient record is involved in litigation and the physician requests to make a change to that record, what should the HIM professional do?

refer request to legal counsel

In general, which of the following statements is correct?

When federal and state laws conflict, valid federal laws supersede state laws.


All of the following have laws (both statutory and administrative code) addressing medical records EXCEPT

CMS COP

Which of the following is an example of breach of confidentiality?

staff members discussing patients in the elevator

One of the greatest threats to the confidentiality of health data is

redisclosure of information for purposes not authorized in writing by the patient


A signed consent for the release of information dated December 1, 2013, is received with a request from the chart from the patient's admission of 12/5/2013. Indicate the appropriate response from the options below.

Request another authorization dated after the discharge date
The sister of a patient requests the HIM department to release copies of her brother's medical record to her. she states that because the doctor documented her name as her brother's caregiver that HIPAA regulations apply and that she may receive copies of her brother's medical record. In this case how should the department director proceed?

refuse the request

A HIT supervisor receives a subpoena duces tecum for the records of a discharged patient. To respond to the subpoena, which of the following should the supervisor do?
Review the subpoena to determine what documents should be produced.
Which of the following statements is TRUE in regard to responding to requests from individuals for access to their PHI?
A cost based fee may be charged for the copying of the PHI.
Which of the following provides a complete description to patients how PHI is used in a healthcare facility?
Notice of Privacy Practices
Which document directs an individual to bring originals or copies of records to court?
subpoena duces tecum


Margaret has signed an authorization to release information regarding her ER visit for a fractured finger to her attorney. Specifically, she says to release the ER history and physical, x-rays, and any procedure notes for finger fracture. Which of the following violates her privacy?

documentation of suturing of finger
The local newspaper has notified the hospital that they have received a computer listing of the names of patients receiving HIV treatment in your facility. What method(s) could be used to identify the source of this breach of confidentiality?
identify all employees whose passwords would permit access to such information

identify where, when, and by whom such data is originated and distributed

a review of computer audit trails to determine who may have accessed such information

You have been asked to define privacy. Which of the following definitions would you use?

Patients have rights regarding their individually identifiable health information.

Rachel, a nurse, can write progress notes in the patient's electronic health record. Vera, a coder, can view the progress notes but is not authorized to write a progress note. What controls this?

role-based access control (i.e: Scope)
Which of the following federal laws passed in 1996 resulted in new privacy regulations for healthcare organizations?
Health Insurance Portability and Accountability Act
Which of the following statements about the directory of patients maintained by a CE is TRUE?
Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory.
Under HIPAA rules, when an individual asks to see his or her PHI a CE
can deny access to psychotherapy notes

the health record is the property of

the facility

the information within the health record belongs to

the patient

There must be a system in place to record the name of every person who views a patient’s record.

true

Explain in detail what the North Carolina MOST form is and how it is used.

The NC MOST form is a legal document of physician's orders. It tells healthcare workers what a patient wants done with their treatment. It includes if they are DNR or not, whether they want hydration/nutrition tubes, to be made comfortable or treated to the full extent.


The attending physician, the physician's assistant, or the nurse practitioner must help the patient fill out the form, and make sure everything is signed and dated.

examples of advance directives

living will, HC POA, Durable POA, HC Agent

One’s moral character can sometimes change as a circumstances change. This thought best reflects:

situational ethics
____________________ is the legal mechanism by which the court declares a person incompetent, and transfers decision making to another.

Durable POA

What is the piece of federal legislation that mandates a patient must be treated upon arrival to the facility. (Meaning they can’t be turned away…..)

EMTALA

This document designates an agent to make healthcare decisions for you, if you should become incapable of doing so.

healthcare POA

Beth Bethesda is a Jehovah Witness and signed a release form for the hospital stating that she did not want any blood transfusions. Beth has a right to refuse this treatment under the:

Patient Self-Determination Act

Guidelines pertaining to withholding of life support state that:

in certain circumstances, it is not unethical to discontinue all means of life-prolonging medical treatment.

A professional code of ethics

serves a guideline for moral conduct for members of a profession

Which of the following is considered an unethical practice?

backdating progress notes

Physician orders for DNR should be consistent with
patient's advance directive
A physician's order for DNR in a patient chart is an example of: Your answer:
passive euthanasia
The word "euthanasia" means:
good death
Which of the following is an example of active euthanasia?
A husband gives his terminally ill wife an overdose

Patients have the right to know the names, positions, and functions of any hospital staff involved in their care. Patients cannot, however, refuse to be treated.

false

A patient has a right to smoke in his or her room. After all, the patient is paying the bill.

false

The Patient Self-Determination Act of 1990 provides that each individual has a right under state law (whether statutory or as recognized by the courts of the state) to make decisions concerning his or her medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.

true

Patients with communicable diseases can be held by a health officer to prevent the spread of infection.

true

It is acceptable to use the terminology “persistent vegetative state” as defined by NC law.

false

A health care agent can “trump” or “override” spousal wishes.

true

A Healthcare POA can be revoked.

true

AHIMA’s Code of Ethics is an example of professional ethics.

true

DNR orders must be signed by the physician to be valid.

true