Rhia- (Prg) - Health Law

Front 1

Referring to Case Study #1, the written statement by Dr. Roberts about Nurse Parrish's professional competence in the patient's medical record can constitute

A. libel.
B. slander.
C. perjury.
D. defamation.

Back 1

A. libel.

Front 2

Referring to Case Study #1, the oral statement by Nurse Parrish about Dr. Roberts's professional practices at the nurses' station can constitute

A. libel.
B. slander.
C. perjury.
D. defamation.

Back 2

B. slander.

Front 3

Referring to Case Study #1, what should Dr. Roberts be reminded of regarding his notation in the patient's chart about Nurse Parrish?

A. It is against the law to mention names of persons who are not actively attending to his patient.
B. His action violates the 1974 Privacy Act.
C. The medical record must not be used as a battleground against another professional.
D. He should erase his note about Nurse Parrish because it is malicious.

Back 3

C. The medical record must not be used as a battleground against another professional.

Front 4

Which type of law is constituted by rules and principles determined by legislative bodies?

A. statutory law
B. administrative law
C. common law
D. case law

Back 4

A. statutory law

Front 5

Which of the following elements of negligence must be present in order to recover damages?

A. duty of care; breach of duty of care; value attached to injury is greater than a certain value (ordinarily $1,000); provisions of the HIPAA Privacy Rule have been met
B. duty of care; breach of the duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000)
C. duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm
D. breach of duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000); provision of HIPAA Privacy Rule have been met

Back 5

C. duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm

Front 6

When the physician failed to give the patient the lips of the famous actress as promised, the physician engaged in which of the following?

A. slander
B. a breach of contract
C. libel
D. invasion of privacy

Back 6

B. a breach of contract

Front 7

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

A. case law.
B. summons.
C. statutes of limitations.
D. common law.

Back 7

C. statutes of limitations.

Front 8

The protection of a patient's health information is addressed in each of the following EXCEPT

A. Health Insurance Portability and Accountability Act.
B. Privacy Act.
C. Drug Abuse and Treatment Act.
D. U.S. Patriot Act.

Back 8

D. U.S. Patriot Act.

Front 9

In a court of law, Attorney A, the attorney for Sun City Hospital, introduces the medical record from the hospital as evidence. However, Attorney B, the attorney for the defendant, objects on the grounds that the medical record is subject to the hearsay rule, which prohibits its admission as evidence. Attorney B's objection is overridden. Why?

A. The medical record does not belong to the hospital; therefore, the hospital has no right to release the medical record as evidence.
B. It would violate physician-patient privilege, even though the patient signed a proper release of information form.
C. The doctrine of res ipsa loquitur prevails; therefore, reference to the medical record is moot.
D. The medical record may be admitted as business records or as an explicit exception to hearsay rule.

Back 9

D. The medical record may be admitted as business records or as an explicit exception to hearsay rule.

Front 10

Medical record information may be exempt from the Freedom of Information Act requirements if the request for information meets the test of being an unwarranted invasion of personal privacy. Which of the following is NOT one of the conditions of the test?

A. The information must be contained in a personal, medical, or similar file.
B. The information is generated from federally funded research conducted by a private health care organization.
C. Disclosure of the information constitutes an invasion of personal privacy.
D. The severity of the invasion must outweigh the public's interest in disclosure.

Back 10

B. The information is generated from federally funded research conducted by a private health care organization.

Front 11

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

A. res ipsa loquitur.
B. respondeat superior.
C. stare decisis.
D. statute of limitations.

Back 11

C. stare decisis.

Front 12

The body of law founded on custom, natural justice and reason, and sanctioned by usage and judicial decision is known as

A. common law.
B. lien law.
C. constitutional law.
D. statutory law.

Back 12

A. common law.

Front 13

Referring to Case Study #2, Barbara Masters is the __________ in this case.

A. appellant
B. appellee
C. defendant
D. plaintiff

Back 13

D. plaintiff

Front 14

Referring to Case Study #2, Bayshore Hospital is the __________________ in this case.

A. appellant
B. appellee
C. defendant
D. plaintiff

Back 14

C. defendant

Front 15

Referring to Case Study #2, the sworn verbal testimony you are asked to provide is called a(n)

A. interrogatory.
B. deposition.
C. physical and mental examination.
D. court order.

Back 15

B. deposition.

Front 16

Referring to Case Study #2, the written answers to questions you have been asked to provide are known as a(n)

A. interrogatory.
B. deposition.
C. physical and mental examination.
D. court order.

Back 16

A. interrogatory.

Front 17

Referring to Case Study #2, what phase of the lawsuit are you involved in?

A. pretrial conference
B. trial
C. discovery
D. appeal

Back 17

C. discovery

Front 18

Which of the following claims of negligence fits into the category of res ipsa loquitur?

A. incorrect administration of anesthesia
B. failure to refer patient to a specialist
C. leaving a foreign body inside a patient
D. improper use of x-rays

Back 18

C. leaving a foreign body inside a patient

Front 19

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

A. battery.
B. contempt.
C. libel.
D. malpractice.

Back 19

A. battery.

Front 20

The fee paid for reimbursement for expenses incurred from providing health information whether for subpoena or reproduction by health care providers is determined by the

A. American Health Information Management Association.
B. hospitals and lawyers.
C. statute or court rules.
D. plaintiff and defendant lawyers.

Back 20

C. statute or court rules.

Front 21

Who determines the retention period for health records?

A. state and federal governments
B. medical staff
C. city and state governments
D. commercial storage vendors

Back 21

A. state and federal governments

Front 22

The extent to which the HIPAA privacy rule may regulate an individual's rights of access is not meant to preempt other existing federal laws and regulations. This means that if an individual's rights of access

A. are less under another existing federal law, HIPAA must follow the directions of that law.
B. are refused by a federal facility, HIPAA must also refuse the individual of the access.
C. are greater under another applicable federal law, the individual should be afforded the greater access.
D. are greater under another existing federal law, HIPAA can obstruct freedoms of the other federal law when using electronic health records.

Back 22

C. are greater under another applicable federal law, the individual should be afforded the greater access.

Front 23

Referring to Case Study #3, the resident's family brought legal action against the nursing facility for

A. medical abandonment.
B. vicarious liability.
C. assault and battery.
D. negligence.

Back 23

D. negligence.

Front 24

Referring to Case Study #3, which of the following can the attorney of the resident's family also use as a basis for the lawsuit and why?

A. 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.
B. The doctrine of charitable immunity because the nursing facility is a private institution and is shielded from liability for any torts committed on its property.
C. The Good Samaritan Statutes because they protect the Director of Nursing, an employee of the nursing facility, who was not present when the injury occurred.
D. The failure to warn theory because the doctor did not inform the resident's family that the resident was in danger at the nursing facility.

Back 24

A. 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.

Front 25

In a negligence or malpractice case, all of the following elements must be present in order to shift the burden of proof onto the defendant EXCEPT the

A. event would not normally have occurred in the absence of negligence.
B. health care facility does not have a risk management program.
C. defendant had exclusive control over the instrumentality that caused the injury.
D. plaintiff did not contribute to the injury.

Back 25

B. health care facility does not have a risk management program.

Front 26

When a health care facility fails to investigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the health care facility can be held liable under

A. respondeat superior.
B. corporate negligence.
C. contributory negligence.
D. general negligence.

Back 26

B. corporate negligence.

Front 27

What source or document is considered the “supreme law of the land”?

A. Bill of Rights
B. Supreme Court decisions
C. presidential power
D. Constitution of the United States

Back 27

D. Constitution of the United States

Front 28

Hospitals that destroy their own medical records must have a policy that

A. ensures records are destroyed and confidentiality is protected.
B. notifies the physicians when the records of their patients are destroyed.
C. states that all records are destroyed annually.
D. ensures that the type of equipment to be used for destruction of records is properly maintained.

Back 28

A. ensures records are destroyed and confidentiality is protected.

Front 29

A written authorization from the patient releasing copies of his or her medical records is required by all of the following EXCEPT

A. the patient's attorney.
B. a physician requesting copies from another physician.
C. an insurance company.
D. the hospital attorney for the facility where the patient

Back 29

D. the hospital attorney for the facility where the patient

Front 30

Traditionally, the medical record is accepted as being the property of the

A. patient's guardian.
B. court.
C. institution.
D. patient.

Back 30

C. institution.

Front 31

The ownership of the information contained in the physical medical/health record is considered to belong to the

A. patient.
B. hospital.
C. physician.
D. insurance company.

Back 31

A. patient.

Front 32

When developing a record retention policy, the HIM professionals should consider all of the following EXCEPT

A. current storage space.
B. uses of and need for information.
C. all applicable statutes and regulations.
D. the thickness of the records.

Back 32

D. the thickness of the records.

Front 33

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?

A. Refer request to legal counsel.
B. Allow the change to occur.
C. Notify the patient.
D. Say the record is unavailable.

Back 33

A. Refer request to legal counsel.

Front 34

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

A. when medical information is reviewed as a part of quality assurance activities.
B. disclosure of information for purposes not authorized in writing by the patient.
C. lack of written authorization by the patient.
D. when medical information is used for research or education.

Back 34

B. disclosure of information for purposes not authorized in writing by the patient.

Front 35

All of the following are areas in which electronically stored information, for example, the electronic health record, differs from paper-based information EXCEPT

A. volume.
B. metadata.
C. variety of sources.
D. confidentiality.

Back 35

B. metadata.

Front 36

Spoliation is the term that refers to the wrongful destruction of evidence or the failure to preserve property, which addresses which of the following methods of discovery?

A. interrogatories
B. deposition
C. e-discovery
D. request for admissions

Back 36

C. e-discovery

Front 37

What type of testimony is inappropriate for a health information manager serving as custodian of the record when he or she is called to be a witness in court?

A. whether the record is in the practitioner's possession
B. title and position held in the health care facility
C. whether the medical record was made in the usual course of business
D. interpretation of documentation in the record

Back 37

D. interpretation of documentation in the record

Front 38

Internal disclosures of patient information for patient care purposes should not be granted

A. to the facility's legal counsel.
B. to the attending physician.
C. on a need to know basis.
D. to a family member who is a registered nurse at the facility.

Back 38

D. to a family member who is a registered nurse at the facility.

Front 39

Referring to Case Study #4, given the emergency of the situation, who should the health care provider seek consent from in order to provide treatment to William?

A. the employer
B. the parents
C. the patient
D. no consent is needed for emergency care

Back 39

D. no consent is needed for emergency care

Front 40

Referring to Case Study #4, in order to release information to his employer, the hospital must receive a

A. consent signed by the patient.
B. court order.
C. consent signed by the doctor.
D. consent signed by the patient's parent.

Back 40

D. consent signed by the patient's parent.

Front 41

A valid authorization for the disclosure of health information should not be

A. dated prior to discharge of the patient.
B. in writing.
C. addressed to the health care provider.
D. signed by the patient.

Back 41

A. dated prior to discharge of the patient.

Front 42

Internal disclosures of patient information for patient care purposes should be granted

A. to legal counsel.
B. on a need to know basis.
C. to any physician on staff.
D. to a family member who is an employee.

Back 42

B. on a need to know basis.

Front 43

According to AHIMA's Position on Transmission of Health Information, the health information manager should engage in all of the following to ensure that information is properly sent via facsimile transmission EXCEPT

A. to always follow up by sending the original record by mail.
B. to preprogram into the machine the number of destination sites.
C. encrypt the data if public channels are used for electronic transmittal.
D. ask the sender to contact the recipient prior to and after transmission

Back 43

A. to always follow up by sending the original record by mail.

Front 44

All of the following need a proper authorization to access a patient's health information EXCEPT

A. local and state law enforcement officers.
B. IRS agents.
C. medical examiners or coroners.
D. FBI agents.

Back 44

C. medical examiners or coroners.

Front 45

One best practice to follow in order to establish safeguards for the security and confidentiality of a patient's information when a person makes a request for his or her records in person is to

A. ask the requester for identification and the request in writing.
B. refuse the request.
C. refer the requester to the facility's attorney.
D. charge an exorbitant fee.

Back 45

A. ask the requester for identification and the request in writing.

Front 46

Which of the following acts was passed to stimulate the development of standards to facilitate electronic maintenance and transmission of health information?

A. Health Insurance for the Aged
B. Health Insurance Portability and Accountability Act
C. Conditions of Participation
D. Hospital Survey and Construction Act

Back 46

B. Health Insurance Portability and Accountability Act

Front 47

The premise that charitable institutions could be held blameless for their negligent acts is known as

A. doctrine of respondeat superior.
B. doctrine of res ipsa loquitur.
C. doctrine of charitable immunity.
D. negligence factor.

Back 47

C. doctrine of charitable immunity.

Front 48

Under traditional rules of evidence, a medical/health record is considered ______________ and is _____________ into evidence.

A. hearsay; admissible
B. hearsay; inadmissible
C. reliable; admissible
D. reliable; inadmissible

Back 48

B. hearsay; inadmissible

Front 49

Substance abuse records cannot be redisclosed by a receiving facility to another health care facility unless the

A. patient expires at the receiving facility.
B. charge nurse signs the release form.
C. physician signs the DNR form.
D. patient gives written consent.

Back 49

D. patient gives written consent.

Front 50

Who is legally responsible for obtaining the patient's informed consent for surgery?

A. the admissions clerk
B. the surgeon performing the surgery
C. the nurse
D. medical records personnel

Back 50

B. the surgeon performing the surgery

Front 51

With regard to confidentiality, when HIM functions are outsourced (i.e., record copying, microfilming, or transcription), the HIM professional should confirm that the outside contractor's

A. costs are not prohibitive, thus compromising confidentiality.
B. hours of operation permit easy access by all health care providers.
C. is contractually bound to handle confidential information appropriately by means of a signed business associate agreement.
D. is located in an easy to find place.

Back 51

C. is contractually bound to handle confidential information appropriately by means of a signed business associate agreement.

Front 52

A 21-year-old employee of National Services was treated in an acute care hospital for an illness unrelated to work. A representative from the personnel department of National Services calls to request information regarding the employee's diagnosis. What would be the appropriate course of action?

A. Request that the personnel office send an authorization for release of information that is signed and dated by the patient.
B. Require parental consent.
C. Release the information because the employer is paying the patient's bill.
D. Call the patient to obtain verbal permission

Back 52

A. Request that the personnel office send an authorization for release of information that is signed and dated by the patient.

Front 53

Darling v. Charleston Community Memorial Hospital is considered one of the benchmark cases in health care because it was with this case that the doctrine of _______________ was eliminated for nonprofit hospitals.

A. charitable immunity
B. corporate negligence
C. professional negligence
D. contributory negligence

Back 53

A. charitable immunity

Front 54

All of the following are elements of a contract EXCEPT

A. offer/communication.
B. duty.
C. price/consideration.
D. acceptance.

Back 54

B. duty.

Front 55

A valid authorization for release of information contains

A. the name, agency, or institution to which the information is to be provided.
B. the name of the hospital or provider who is releasing the medical information.
C. the date and signature of the patient or the patient's authorized representative.
D. all of the above.

Back 55

D. all of the above.

Front 56

In which of the following circumstances would release of information without the patient's authorization be permissible?

A. release to an attorney
B. release to third-party payers
C. release to state workers' compensation agencies
D. release to insurance companies

Back 56

C. release to state workers' compensation agencies

Front 57

Who decides whether all or portions of the medical record will be received in evidence in a court of law?

A. presiding judge/court
B. subpoenaing attorney
C. clerk of the court
D. defendant

Back 57

A. presiding judge/court

Front 58

Which of the following health care systems have to comply with the requirements of the Freedom of Information Act?

A. private hospitals
B. physicians' offices
C. veterans' hospitals
D. single-day surgery clinics

Back 58

C. veterans' hospitals

Front 59

Which of the following measures should a health care facility incorporate into its institution-wide security plan to protect the confidentiality of the patient record?

A. verification of employee identification
B. locked access to data processing and record areas
C. use of unique computer passwords, key cares, or biometric identification
D. all of the above

Back 59

D. all of the above

Front 60

A signed consent for release of information dated December 1, 2010, is received with a request for the chart from the patient's admission of 12/5/2010. Indicate the appropriate response from the options below.

A. Request another authorization that is dated closer but prior to the admission date.
B. Request another authorization dated after the discharge date.
C. Release the requested information.
D. Call the patient for a verbal authorization.

Back 60

B. Request another authorization dated after the discharge date.

Front 61

Willful disregard of a subpoena is considered

A. breach of contract.
B. abuse of process.
C. contributory negligence.
D. contempt of court.

Back 61

D. contempt of court.

Front 62

HIM personnel charged with the responsibility of bringing a medical record to court would ordinarily do so in answer to a

A. personal subpoena.
B. deposition.
C. subpoena duces tecum.
D. judgment.

Back 62

C. subpoena duces tecum.

Front 63

HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets forth all of the following EXCEPT

A. covered entities provide every patient with its annual business report.
B. how covered entities may use and disclose PHI.
C. patient's rights regarding the covered entities' uses and disclosures.
D. covered entities' obligations for protecting the patient's PHI.

Back 63

A. covered entities provide every patient with its annual business report.

Front 64

A record that has been requested by subpoena duces tecum is currently located at an off-site microfilm company. By contacting the microfilm provider, you learn that the microfilm is ready and the original copy of the record still exists. What legal requirement would compel you to produce the original record for the court?

A. best evidence rule
B. hearsay rule
C. motion to quash
D. subpoena instanter

Back 64

A. best evidence rule

Front 65

Under which category of law would Marleana Harrison bring a cause of action against Dr. Billy Ray for disclosing information regarding her previous physical examination to his wife, Jana Ray, who is Ms. Harrison's hairstylist?

A. administrative law
B. criminal law
C. private law
D. procedural law

Back 65

C. private law

Front 66

As a general rule, a person making a report in good faith and under statutory command (e.g., on child abuse, communicable diseases, births, deaths, etc.) is

A. not protected from liability claims.
B. subject to penalties imposed by federal law.
C. subject to penalties imposed by state law.
D. protected.

Back 66

D. protected.

Front 67

According to AHIMA and AHA guidelines, which of the following would be an acceptable authorization for release of information from the medical record of an adult, mentally competent patient hospitalized from 4/16/2011 to 5/10/2011? An authorization dated

A. 7/10/2013 and presented 7/15/2013
B. 5/09/2013 and presented 1/15/2014
C. 3/10/2013 and presented 5/15/2013
D. 2/15/2013 and presented 1/10/2013

Back 67

A. 7/10/2013 and presented 7/15/2013

Front 68

Which would be the better “best practice” for handling fax transmission of a physician's orders?

A. Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required period.
B. Faxed orders should be placed on the patient's chart immediately upon receipt after the head nurse signs the orders.
C. Wait 24 hours before placing faxed orders on the patient's chart to ensure that the orders are legitimate.
D. Faxed orders should never be accepted.

Back 68

A. Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required period.

Front 69

The Darling v. Charleston Community Memorial Hospital case established the following doctrine for hospitals to observe and changed the way hospitals dealt with liability.

A. doctrine of respondeat superior
B. doctrine of continuing wrong
C. doctrine of res ipsa loquitur
D. doctrine of corporate negligence

Back 69

D. doctrine of corporate negligence

Front 70

HIM professionals have a duty to maintain health information that complies with

A. state statutes.
B. federal statutes.
C. accreditation standards.
D. all of the above.

Back 70

D. all of the above.

Front 71

In general, which of the following statements is correct?

A. When federal and state laws conflict, valid federal laws supersede state laws.
B. When federal and state laws conflict, valid state laws supersede federal laws.
C. When federal and state laws conflict, valid local laws supersede federal and state laws.
D. When federal and state laws conflict, valid corporate policies supersede federal and state laws.

Back 71

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

Front 72

Which of the following statements is correct regarding HIPAA preemption analysis?

A. If the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the state law prevails.
B. State law regarding a patient's right to health care information privacy can never prevail over the HIPAA federal rule.
C. If a state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the courts must decide which shall prevail.
D. Even if the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, the HIPAA federal rule will still prevail.

Back 72

A. If the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the state law prevails.

Front 73

The minimum record retention period for patients who are minors is

A. age of majority.
B. age of majority plus the statute of limitations.
C. 5 years past treatment.
D. 2 years past treatment.

Back 73

B. age of majority plus the statute of limitations.

Front 74

In which type of facility does the Privacy Act of 1974 permit patients to request amendments to their medical record?

A. private proprietary health care facility
B. mental health and chemical dependency facility
C. university-based teaching facility
D. Department of Defense health care facility

Back 74

D. Department of Defense health care facility

Front 75

What advice should be given to a physician who has just informed you that she just discovered that a significant portion of a discharge summary she dictated last month was left out?

A. Squeeze in the information omitted by writing in available spaces such as the top, bottom, and side margins.
B. Dictate the portion omitted with the heading “Discharge Summary—Addendum” and make a reference to the addendum with a note that is dated and signed on the initial Discharge Summary (e.g., “9/1/11—See Addendum to Discharge Summary”—Signature).
C. Redictate the discharge summary and replace the old one with the new one.
D. Inform the physician that nothing can be done about the situation.

Back 75

B. Dictate the portion omitted with the heading “Discharge Summary—Addendum” and make a reference to the addendum with a note that is dated and signed on the initial Discharge Summary (e.g., “9/1/11—See Addendum to Discharge Summary”—Signature)

Front 76

While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation?

A. Remove the incident report and send it to the patient.
B. Tell the employee to leave the report in the record.
C. Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record.
D. Refer this record to the Risk Manager for further review and removal of the incident report.

Back 76

D. Refer this record to the Risk Manager for further review and removal of the incident report.

Front 77

Which of the following is considered confidential information if the patient is seeking treatment in a substance abuse facility?

A. patient's name
B. patient's address
C. patient's diagnosis
D. all of the above

Back 77

D. all of the above

Front 78

In electronic health records, authentication may be achieved by

A. handwritten signature.
B. digital signature.
C. verbal statement.
D. all the above.

Back 78

B. digital signature.

Front 79

It is common practice to forgo patient authorization for the release of information when the

A. patient is an employee.
B. patient is a physician.
C. patient has a direct transfer from the hospital to a long-term care facility.
D. patient is incompetent.

Back 79

C. patient has a direct transfer from the hospital to a long-term care facility.

Front 80

Many states have recognized a minor's right to seek treatment without parental consent in all of the following situations EXCEPT a(n)

A. minor seeking treatment for breast reduction.
B. minor seeking treatment for a sexually transmitted disease.
C. minor seeking treatment for alcohol and substance abuse.
D. emancipated minor seeking treatment for breast enlargement.

Back 80

A. minor seeking treatment for breast reduction.

Front 81

When a health information professional (record custodian) brings the medical record to court in response to a subpoena duces tecum, it is his or her responsibility to

A. confirm whether or not the record is complete, accurate, and made in the ordinary course of business.
B. present the case favorably for the patient involved.
C. leave the original record in the possession of the plaintiff's attorney.
D. explain details of the medical treatment given to the patient.

Back 81

A. confirm whether or not the record is complete, accurate, and made in the ordinary course of business.

Front 82

When substituting a photocopy of the original record in response to legal process, which of the following can be helpful in convincing the court to accept the photocopy as a true and exact copy of the original?

A. certificate of authentication
B. consent from the patient
C. consent from the hospital administrator
D. correspondence from the attending physician

Back 82

A. certificate of authentication

Front 83

Which of the following should be required to sign a confidentiality statement before having access to patients' medical information?

A. nursing students
B. medical students
C. HIM students
D. all of the above

Back 83

D. all of the above

Front 84

All of the following have laws and regulations addressing medical records EXCEPT

A. accrediting agencies.
B. corporate law.
C. state laws.
D. federal laws

Back 84

B. corporate law.

Front 85

The proper method for correcting a documentation error in a medical record is for the author to

A. draw an “X” through the incorrect documentation.
B. draw a single line through the incorrect information, date and initial the change.
C. white it out, date and initial the change.
D. remove the form from the chart and add a revised form

Back 85

B. draw a single line through the incorrect information, date and initial the change.

Front 86

Dr. Vincent Orangeburg performed a cesarean on Mrs. Greentree, who later returned to the emergency room 5 days after the surgery with abdominal pain. An x-ray performed revealed that a sponge was left in the lower abdominal cavity from the cesarean. Which case law principle can be used in a lawsuit against Dr. Orangeburg?

A. res gestae
B. star decis
C. res ipsa loquitur
D. res judicata

Back 86

C. res ipsa loquitur

Front 87

To be admitted into court as evidence, medical records or health information are introduced as

A. torts or contracts.
B. privileged information.
C. business records or exception to hearsay rule.
D. product liability.

Back 87

C. business records or exception to hearsay rule.

Front 88

A health care organization's compliance plans should not only focus on regulatory compliance, but also have a

A. strong personnel component that reduces the rapid turnover of nursing personnel.
B. coding compliance program that prevents fraudulent coding and billing.
C. component that increases the security of medical records.
D. substantial program that increases the availability of clinical data.

Back 88

B. coding compliance program that prevents fraudulent coding and billing.

Front 89

A written consent from the patient is required from which of the following entities in order to learn a patient's HIV status?

A. insurance companies
B. emergency medical personnel
C. spouse or needle partner
D. health care workers

Back 89

A. insurance companies

Front 90

Dr. Sam Vineyard improperly performed a knee replacement surgery, which caused the patient to develop an infection that lead to the amputation of the leg and thigh. The best term to describe the action performed is

A. misfeasance.
B. malpractice.
C. nonfeasance.
D. malfeasance.

Back 90

A. misfeasance.

Front 91

The ideal consent for medical treatment obtained by the physician is

A. expressed.
B. informed.
C. implied.
D. verbal.

Back 91

B. informed.

Front 92

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

A. a nurse speaking with the physician in the patient's room.
B. staff members discussing patients in the elevator
C. the admission clerk verifying over the phone that the patient is in-house
D. the hospital operator paging code blue in room 3 north

Back 92

B. staff members discussing patients in the elevator

Front 93

Which of the following would be an inappropriate procedure for the custodian of the medical record to perform prior to taking a medical record from a health care facility to court?

A. Number each page of the record in ink.
B. Document in the file folder the total number of pages in the record.
C. Remove any information that might prove detrimental to the hospital or physician.
D. Prepare an itemized list of sheets contained in the medical record.

Back 93

C. Remove any information that might prove detrimental to the hospital or physician.

Front 94

Which of the following agencies is empowered to implement the law governing Medicare and Medicaid?

A. Centers for Medicare and Medicaid Services (CMS) formerly known as Health Care Financing Administration (HCFA)
B. Joint Commission
C. Institutes of Health
D. Department of Health and Human Services

Back 94

A. Centers for Medicare and Medicaid Services (CMS) formerly known as Health Care Financing Administration

Front 95

Consent forms may be challenged on all the following grounds EXCEPT

A. wording was too technical.
B. the treating physician obtained the patient's signature.
C. it is written in a language that the patient could not understand.
D. the signature was not voluntary.

Back 95

B. the treating physician obtained the patient's signature.

Front 96

Mandatory reporting requirements for vital statistics generally

A. do not require authorization by the patient.
B. require authorization by the physician.
C. require authorization by the payer.
D. do not apply to health care facilities.

Back 96

A. do not require authorization by the patient.

Front 97

The responsibility of obtaining an informed consent for a surgical or invasive procedure rests with the

A. patient.
B. nurse.
C. physician.
D. hospital.

Back 97

C. physician.

Front 98

Courts have released adoption records based on

A. the request of the adoptee.
B. the request of the biological parent(s).
C. the Freedom of Information Act.
D. a court order for good cause.

Back 98

D. a court order for good cause.

Front 99

The legislation that required all federally funded facilities to inform patients of their rights under state law to accept or refuse medical treatment is known as

A. advance directives.
B. living wills.
C. Patient Self-Determination Act.
D. durable power of attorney.

Back 99

C. Patient Self-Determination Act.

Front 100

An improper disclosure of patient information to unauthorized individuals, agencies, or news media may be considered a(n)

A. invasion of privacy.
B. libel.
C. slander.
D. defamation.

Back 100

A. invasion of privacy.

Front 101

CASE STUDY #1

Dr. Roberts, an orthopedic surgeon, and Nurse Parrish, head nurse on the orthopedic surgery unit, have had an acrimonious working relationship for years. While making rounds on the unit, Dr. Roberts discovered that the physical therapy evaluation he had ordered for one of his patients had not been performed and became outraged. Even though he did not have proof, Dr. Roberts placed the blame for the missed evaluation with Nurse Parrish. Dr. Roberts wrote in the patient's medical record that Nurse Parrish failed to properly order the physical therapy evaluation because she was incompetent and could not be trusted to carry out even the simplest order. After having read Dr. Roberts's note, Nurse Parrish countered by making a disparaging remark about Dr. Roberts to the medical personnel at the nurses' station. Nurse Parrish stated that Dr. Roberts was the one who was incompetent and was responsible for the needless suffering of countless patients over the years.

Back 101

N/A

Front 102

CASE STUDY #2

You are the Director of the Health Information Management Department for Bayshore Hospital. 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.

Back 102

N/A

Front 103

CASE STUDY #3

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 facility's attendants.

Back 103

N/A

Front 104

Case Study #4

William is a 16-year-old male who lives at home with his parents and works part-time as a dishwasher at one of the local restaurants. While emptying the dishwasher, William is severely scalded and rendered unconscious. He is taken to the emergency room of the local acute care hospital for emergency treatment.

Back 104

N/A