HIM 226 Legal & Ethical Aspects of HIM TEST 3 (Chapters 8-11)
After the destruction of records, a certificate of destruction ____. a. Indicates what was destroyed as well as the method of destruction b. May implicate the healthcare organization and providers in a legal action c. Often proves unnecessary because the health records no longer exist d. Applies only if the destruction of records was performed by a third party
A
Which is an example of medical information associated with the health record? a. Alcohol, tobacco, and work history b. Test results and operative reports c. Third-party payer information d. Demographic data, such as address
B
Which is an example of emancipation of a minor? a. Minor who no longer lives with parents. b. 14-year-old female who has an STD. c. Mentally competent 10-year old child. d. 17-year-old who enters the armed forces.
D
According to HIPAA, the _____ has the right to access patient information in the complete medical record. a. patient b. transferring facility c. payer d. government
A
The phrase deeming authority means to substitute compliance with _____. a. Has been eliminated by CMS b. Saves time for physicians and their designees c. Proves to be a best practice standard d. Is considered acceptable by CMS
A
The proper disclosure of home health care records is regulated by _____. a. Medicare conditions of participation b. Patient legal representatives c. Family members of the patient d. Health care facility policies
A
Third parties are required to obtain the patient's permission when _____ wish to access the patient's protected health information. a. Children of elderly parents b. Medicare and Medicaid payers c. Health care facility's legal attorneys d. Accrediting and licensing agents
A
Which of the following are subject to strict legal requirements? a. Records, regardless of format b. Paper-based record c. Electronic record d. Abstract record
A
Which statement about the substance abuse treatment is true? a. In certain circumstances, parental consent is required to authorize treatment. b. Minors are not permitted to authorize the release of substance abuse information. c. Depending on their age, minors are permitted to sign a consent to treatment. d. Substance abuse facilities allow either the minor or parent to authorize treatment.
A
The right to privacy is not specifically mentioned in the U.S. Constitution, but the U.S. Supreme Court has determined that a fundamental right to privacy exists. However, the patient's interests versus the public's right to know must be balanced and sometimes the courts will find that although a patient has a right to privacy, that right is overridden by the public's right to know, such as in the _____ court case. a. Bing v. Thunig b. Whalen v. Roe c. Darling v. Charleston Hospital d. Schindler Schiavo v. Schiavo
B
To determine if the information provided was sufficient to obtain informed consent, the element of _____ is required. a. Possible alternative payment plans b. Description of possible complications c. Costs associated with the procedure d. Treatment, payment, operations
B
When an error is made in the healthcare record, _____. a. Eliminating the erroneous information by using correction fluid in a paper-based record is an acceptable practice b. An addendum to the EHR or paper-based record should be documented, leaving the original entry in place c. Make sure that the erroneous entry is deleted in its entirety, and the correct information is entered d. The correction to the record should be made by the healthcare provider's supervisor toenhance reliability
B
When obtaining informed consent, which information must be part of the process? a. Obtaining patient's insurance information. b. Documentation that discussion occurred. c. Use of electronic health record (EHR). d. Release of liability statement from patient.
B
Which of the following is a difference between confidentiality and privacy? a. Confidentiality is patients' ability to prevent access to all forms of health information from all entities. b. Privacy is the right that patients have to be left alone and to control access to their health information. c. Privacy is an institution's obligation to prevent unauthorized access to patients' health information. d. Confidentiality is the right that all patients have to completely control access to their health information.
B
Which statutes a category of confidentiality protection at the state level? a. Mandated redisclosure b. Physician-patient privilege c. Professional disclosure d. Common law liability
B
Federal confidentiality requirements are provided to a patient when _____. a. Facilities receive a discovery request pursuant to a lawsuit b. They are discharged from a substance abuse treatment program c. Patients are admitted to a substance abuse treatment program d. Payers request records to verify treatment prior to approving payment
C
Health information becomes confidential _____. a. Until the patient no longer receives provider services b. Only when it contains particularly sensitive information c. After it is made available to the healthcare provider d. When the patient expressly indicates it is not to released
C
In a negligence claim, the standard of care that considers the prevailing is the _____. a. Hospital standard or policy b. State statute/regulation c. Standard that is higher d. Federal statute/regulation
C
Record retention policies address _____. a. Which records can be provided pursuant to court order b. When the record can be released to the patient c. The length of time a record is maintained d. Whether a patient's record warrants storage
C
The minimum necessary standard refers to the healthcare provider's effort to _____. a. Provide the patient with the minimum amount of procedures and medications to maintain reasonable insurance costs b. Invoice third-party payers for the least reasonable amount associated with care provided to the patient c. Limit patient-specific health information released to that which is needed to accomplish the intended purpose only d. Minimalize the risk of negligence that would result in becoming involved in a malpractice lawsuit
C
The role of an Institutional Review Board involves: a. Maintaining the confidentiality of all of the subjects is optional when the results of research benefit society as a whole. b. Reviewing the research protocols to be sure that they comply with federal regulations only, regardless of the facility's location. c. Approving an informed consent that accurately describes the risks and benefits to the subject associated with any research to be conducted. d. Developing means and methods of obtaining financial resources that positively impact research, even if adversely impacting subjects.
C
Which are subject to federal regulations regarding drug and alcohol treatment programs? a. Mental health care organizations that provide long term care for psychiatric patients. b. Facilities that provide general health care and substance abuse diagnosis/treatment. c. General hospitals that operate a substance abuse unit that diagnoses and treats patients. d. Physician offices that provide family medicine care, including treatment of anxiety.
C
Which is a HIPAA Privacy Rule exceptions to the requirement that consent to release protected health information (PHI) be obtained prior to disclosure? a. Adverse events involving provider negligence. b. Non-violent trauma that results in emergency care. c. Instances concerning victims of abuse or neglect. d. Contained accidental chemical exposure.
C
Which is a government agency that is responsible for assuring compliance with ethical conduct of research in humans? a. CMS b. OIG c. FDA d. IRB
C
Which is required of psychiatric facilities that receive Medicare funds? a. Provision for signed disclosure with each billing submission. b. Requirement that patients are informed about record audits. c. Adherence to conditions of participation for documentation. d. Compliance with state mental health codes and regulations.
C
Which statement is associated with federal regulations regarding the patient identification in a substance abuse program? a. Federal regulations prevent a substance abuse program from disclosing patients who were not treated in their program. b. General hospitals are prohibited from revealing patient admission status, even when the diagnosis is not substance abuse related. c. A substance abuse treatment facility has an unconditional obligation not to identify patients who have been treated. d. Providers are permitted to release patient identification information related to substance abuse treatment at their office.
C
Prior to the development of the informed consent doctrine, which theory would have been used to hold a physician accountable for his actions? a. Charitable immunity b. Autonomy c. Good Samaritan d. Battery
D
Standards that apply to facilities providing mental health, mental retardation, and developmental disability services are promulgated by the _____. a. Americans with Disabilities Association b. Department of Health and Human Services c. Office of the Surgeon General d. Joint Commission
D
The confidentiality of HIV information _____. a. Is protected in the same manner as any other type of protected health information, including inpatient stays and outpatient encounters b. Does not require disclosure to the patient that re-release of such information was performed if in the best interest of the general public c. Restricts identification of the patient tested and the reason for testing, but not results of the test, whether positive or negative d. Means a positive test result can be disclosed without prior consent to protect the public if actions are taken to protect the patient's identity
D
The disclosure of mental health records to _____ may be made without express patient authorization. a. Attorneys requesting information through discovery b. Family members of the mental healthcare patient c. Clergy and representatives of the patient's church d. Treating healthcare personnel within the facility
D
Which is an example of acceptable authentication of a medical record entry? a. Physician who authenticates reports dictated by colleagues within his practice. b. Nurse who authenticates notes documented by another nurse who went off shift. c. Nurse practitioner who authenticates notes documented by the physician. d. Specialist who authenticates his own dictated report electronically using a password.
D
Which is an example of personal information associated with the health record? a. Third-party payer information b. Alcohol, tobacco, and work history c. Test results and operative reports d. Demographic data, such as address
D
A release of information (ROI) authorization signed and dated by the patient is considered invalid when it _____. a. Lacks a specific description of the information requested b. Contains information that may implicate the provider in negligence c. Meets the facility's ROI policy as well as HIPAA requirements d. Includes medical information about unnamed family members
A
An authorization for use or disclosure of patient-specific health information that has been combined with any other document is called a(n) _____ authorization. a. Compound b. Beneficence c. Admissibility d. Certiorari
A
ECRM legislation controls _____. a. All forms of data and the tools used to generate and store it b. Privacy and confidentiality of healthcare information c. Only business and financial records maintained on patients d. Just the contents of electronic tools, such as computers
A
Informed consent is a _____. a. Document attesting to the patient's agreement to treatment permitted or provided b. Result of the patient having verbally stated that she is willing to undergo treatment c. Legal theory of permission that was denied prior to a physician performing treatment d. Process of discussion that occurs between the patient and the patient representative
A
State laws may provide additional requirements regarding mental health care documentation in excess of federal regulations, such as _____. a. Written program plans with goals of treatment b. Companies used to purchase physical restraints c. Staffing requirements for electroshock therapy d. Jury sequestering during trials involving patients
A
Accrediting standards _____. a. Demonstrate that a facility needs to improve treatment provision and staff b. May be used in establishing a standard of care during a negligence action c. Are enforceable by law, regardless of whether federal or state in origin d. Have no bearing on malpractice or negligence actions brought by patients
B
Genetic information _____. a. Never impacts potential or current employers' actions against employees b. Can be found in different forms and in different part of a health record c. Provides a look into past health information about a particular patient d. Is protected from discrimination by the Health and Human Services Dept.
B
HIPAA addresses genetic testing by _____. a. Allowing pre-employment screening of prospective employees prior to hiring them b. Prohibiting it from being considered a preexisting condition for health insurance c. Requiring it for government employees for the purpose of granting promotions d. Determining insurance premiums criteria (e.g., charging higher premiums)
B
HIPAA provides for two exceptions in which approval for research does not require full IRB review. They include _____. a. Identified information and waiver or authorization b. Limited data set and de-identified information c. Minimum data set and UHDDS information d. Research that meets criteria for emergency review
B
Institutional standards of care _____. a. Are enforceable by federal and state law b. Do not carry the force of law c. Have no bearing on establishing negligence d. Can be lower than state and federal regulations
B
The Privacy Act of 1974 _____. a. Focuses on private sector records b. Presumes that information be kept confidential c. Does not apply to government records d. Mandates disclosure of information
B
The use of physician handwritten signature stamps to authenticate health record entries _____. a. Proves to be a best practice standard b. Saves time for physicians and their designees c. Has been eliminated by CMS d. Is considered acceptable by CMS
C
What are two main differences between mental health records and general health records? a. Medical record retention regulations and policies as well as issues related to timely entries are more stringent for general health records b. Accurate provider documentation as well as timely entries are stricter for mental health records as compared with general health records c. Additional requirements for patient record content and more stringent privacy requirements are associated with mental health records d. The accuracy of entries in both types of patient records as well as consents required for the release of information are subject to HIPAA regulations
C
Which concept provides the original basis for maintaining confidentiality between patient and healthcare provider? a. HIPPA b. Bill of Rights c. Hippocratic Oath d. Informed Consent
C
A living will provides _____. a. Clarification about who will make healthcare decisions in the event of the patient's recovery from illness b. Instructions regarding the executor of an estate and how assets will be distributed upon the patient's death c. Legal decisions that the family's wishes with regard to the patient's health care when the patient has expired d. Direction about what medical care is to be provided in the event of incapacitation or inability to make decisions
D
A notice regarding redisclosure of information of substance abuse treatment records _____. a. varies among states b. is needed for minor patients only c. applies only to litigation d. must accompany any disclosure
D
A patient's friend or family may be given access to medical records in the event that the _____. a. Friend is the patient's local church pastor or minister b. Health care facility has no policy regarding ROI c. Patient would otherwise unreasonably object to access d. Family member is the custodial parent of a minor child
D
Good Samaritan laws provide legal protection for _____ treatment. a. Elective b. Negligent c. Healthcare d. Unauthorized
D
