MA FInal for Law and Ethics

Maggie knows that the four identified patients must be notified within ____________ days.

60

What is a privilege?

A legal right to keep information confidential and protect it from subpoena or discovery

Which of the following scenarios is considered an incidental disclosure?

A member of the housekeeping staff overhears two physicians discussing as case in the break room

The manager of the HIM department serves as an excellent role model for the HIM profession by addressing data quality issues. Which one of the following is another example of how a manager or supervisor can serve as a role model? The HIM manager

All answers are correct.

Which patient right may be violated if there are duplicate or overlapping record numbers for one patient?

All of the Patient Rights under HIPAA may be violated

The Notice of Privacy Practices (NPP) must be:

All of the above

Under HIPAA, a patient has which of these rights?

All of the above

What can happen to a person who knowingly violates patient privacy for personal gain or malicious harm?

All of the above

Which of the following are some common physical safeguards designed to protect confidentiality of health information contained in patient medical records?

All of the above

In the video, "Case: Encoder System Update", what impact could the delay in instituting the coding updates have on the organization?

All of these may occur

The passage of the American Recovery and Reinvestment Act of 2009 (ARRA) reinforced patient rights by

Allowing patients the right to obtain a copy of their protected health information in electronic format.

HIPAA is one of the examples of interaction between the three branches of government. What is another example?

American Recovery and Reinvestment Act (ARRA)

Why is it legally not proper for a physician in a group practice to sign medical entries made by another physician in the same practice?

Authorization by the same physician who made the entry is necessary for admissibility.

How does a properly documented health record reduce the risk to a health care facility?

Benefits a health care facility's defense

In the video, "Case: Breach of Information Security," the former employee who forwarded protected health information (PHI) to the newspaper was able to do so because his hospital password had not been deleted. This failure to delete a terminated employee's password is called

Breach of protocol

How does the business associate rule apply to the electronic health record?

Business associates qualify under HIPAA and its accompanying regulations, and are subject to business contracts in maintaining and/or storage of electronic health records.

In the video, "Case: Encoder System Update", which of the following statements regarding the Center of Medicare and Medicaid Services (CMS) is true?

CMS no longer gives a grace period.

Which of the following concerning ethical challenges are specifically related to the role of the HIM professional?

Coding, reimbursement, protecting sensitive patient information, quality review

In the video, "Case: Employee Counseling", specific steps were given to resolve quality problems. These steps include all of the following except

Computer assisted instruction

What is the concept of computer sabotage and how can the dangers it poses can be minimized?

Computer sabotage may be a computer virus or the altering of data by hackers. These dangers can be minimized by using antivirus software and firewalls, and limiting the number of access attempts.

Snezana is a registration clerk at a small hospital. Her position requires her to enter the patient's demographic information and personal identification number, and cross check to make sure the patient is assigned to only one medical record number. Snezana sometimes "forgets" to run the designated software to cross check MR numbers with patient's names. Besides, it takes too long, and it really doesn't matter. Snezana is experiencing a(n)

Conflict of interest

What is the National Practitioner Data Bank, and how does a health care institution use the data it contains?

Data concerning malpractice payments, licensure actions, and adverse actions

All of the following pieces of information are considered individually identifiable health information except:

Diagnosis

Which of the following would not be considered an ethical role appropriate for a supervisor or manager?

Discussing employee performance with employee's peers

In the video, "A Death of One's Own", what ethical issues were raised when you consider physician-assisted death and terminal sedation in the context of the case studies portrayed in the film?

Double-effect principle and nonmaleficence

Which of the following is not a method of discovery?

E-mail documentation trail

How is authentication represented in an electronic record?

Electronic signature

What protections from the physical environment should be in place to protect an electronic health record?

Environmental controls, fire alarms, and limited access to computer terminals

A health record serves as a legal document by

Establishing whether the applicable standard of care was met.

In the video, "HIPAA Compliance Analysis", the HIM Director overheard the staff discussing patient information, which is considered a HIPAA violation; this action may also go against which one of the following?

Ethical guidelines issued by professional organizations

In the video, "Fulfilling a Subpoena for the Record of a Deceased Patient", a quality improvement initiative was started to assure that

Every record is complete when filed.

All three branches of the government have a role in HIPAA. Congress creates the statute. What are the other two branches and what do each of them do?

Executive branch enforces; judicial branch resolves ligation

The Notice of Privacy Practices:

Explains how the medical facility will use or disclose patients' protected health information

In the video, "A Death of One's Own", the right to die addresses many fears including fear of losing control over one's life, fear of a prolonged death due to medical interventions, and fear of this as illustrated in the video.

Fear of degradation/lack of dignity

How can an electronic health record be corrected?

Follow the protocol for paper records.

HIPAA offers protection against

Genetic discrimination for health insurance purposes.

What impact do licensing authorities and accrediting organizations have on a health care provider's decision to adopt an electronic health record (EHR) system?

Govern how the transformation to an electronic health record occurs and place requirements and limits upon an EHR

Policies and procedures will need to be developed and shared with pertinent members of the hospital system who may be responsible for preservation of ESI. Who should be responsible for developing the policies and procedures?

HIM, legal counsel, IT, and risk management

Which regulation prohibits genetic information (absent a diagnosis of a condition) from being considered a preexisting condition for health insurance purposes?

HIPAA

Legal requirements for home health care can come from all of the following except

HIPAA.

The most important reason for understanding the sources of law and the separate branches of government is to

Have a better understanding of government regulation of health care.

HIPAA stands for

Health Insurance Portability and Accountability Act

What does the acronym HIPAA stand for?

Health Insurance Portability and Accountability Act

Which of the following is not considered a "covered entity" under HIPAA?

Healthcare consultant

In the video, "Fulfilling a Subpoena for the Record of a Deceased Patient", which of the following was not a problem that the HIM director had to manage?

Hospital was being sued

When is the patient's authorization to release information required?

In most cases when patient information is going to be shared with anyone for reasons other than treatment, payment, or healthcare operations

If a patient wants to request a restriction on the disclosure of his/her protected health information (PHI):

It must be in writing

Health information can be disclosed without patient authorization to which of the following:

Law enforcement officials undertaking a criminal investigation where state laws apply

Which of the following is not part of a hospital incident?

Medical records being destroyed during the course of the business day

What are the advantages of completing an incident report immediately after an incident?

Memories are fresh at the time of the incident, increasing the accuracy of the completed incident report.

In the video, "Case: Breach of Information Security," the patients included in the list sent to the newspaper will need to be notified of the breech. This is part of what process?

Mitigation

The HIM supervisor must have increased accountability and be more alert to ethical issues due, in part, to which ethical roles?

Monitoring employee conduct, serving as a role model, and encouraging ethical behavior

It has been the practice to leave the records system on a computer open and logged on at the nurses' station at the end of a shift to save time for staff who need to retrieve records. Is this allowed?

No

Let's revisit the AHIMA Code of Ethics that was discussed in an earlier chapter. In the video, "Case: Encoder System Update", is Vanessa, the coding supervisor, upholding her ethical obligation to the hospital, patients, and herself regarding the code updates?

No. The updates should have already been installed to assure accurate and compliant coding and reimbursement.

Which division of the Department of Health and Human Services is responsible for administering and enforcing HIPAA privacy and security standards?

Office of Civil Rights (OCR)

What steps should be taken to ensure personnel security in an electronic health record environment?

Ordinary checks for references along with screening for past criminal history and record of computer hacking

In the video, "A Death of One's Own", what type of euthanasia did Jim Wickard select?

Passive euthanasia (DNR)

In the video, "Fulfilling a Subpoena for the Record of a Deceased Patient", the missing documentation was originally from the ______________ department.

Pathology

Which of the following is not one of the steps of the utilization review process?

Peer review

What is admissibility, and how does it apply to the electronic health record?

Pertinent evidence that may be considered by the judge rendering decisions in a lawsuit; it applies to EHR in the submission of a computer printout as evidence of patient care

In the video, "Case: Breach of Information Security," which of the following is not an example of mitigation that could be used?

Placing a notice in the newspaper about the breach

The person who initiates a lawsuit is called the

Plaintiff

Quasi-legal requirements can be defined as

Policies, procedures and medical staff bylaws created by the health care organization

Who is responsible for addressing patient complaints about privacy?

Privacy officer

In the video, "Case: Employee Counseling", a period of time when employees prove themselves before earning a permanent place on the staff is called a/an

Probationary period

In a general health record, entries are made by professionals such as physicians and nurses; in a specialized health record, entries may also be made by paraprofessionals such as teachers and counselors. This is significant because

Professionals are governed by statutes, rules, and professional guidelines that direct patient care and documentation.

Which group is responsible for monitoring the appropriateness and quality of outcomes during a utilization management review?

QIO

Define an electronic health record.

Record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff

In the video, "HIPAA Compliance Analysis", which one of the following was not identified as a HIPAA violation?

Records inadvertently faxed to other hospitals

In the video, "Case: Employee Counseling", what type of employee would Amanda be considered?

Regular employee

Looking through the Davidson Memorial policy and procedure manual concerning breaches, Maggie is reminded that she must contact the _________________ concerning the breach.

Secretary of Health and Human Services

After creating complete and accurate birth certificates to replace ones that were found to be incomplete and inaccurate, how should the old birth certificates be handled?

Shred, burn, or recycle the older birth certificates.

Dolores points out that when a court order or subpoena is received requesting ESI, certain steps must be taken to protect that information from _____.

Spoliation

What legal requirements apply to a record retention policy?

Statute of limitations

For a psychiatric facility receiving Medicare funds, Medicare Conditions of Participation establish standards for all of the following except

Submitting patient records to private insurance for reimbursement.

In the video, "Fulfilling a Subpoena for the Record of a Deceased Patient", if the autopsy report was not requested by the attorney, then

The HIM department would still be responsible for the completeness of the record.

A patient can make personal decisions concerning acceptable treatments; a patient can also make the decision to decline treatment or care. Which of the following is one of the most successful efforts in moving the concept of patient rights from an ethical basis to a legal basis?

The Patient Self-Determination Act

In comparing and contrasting the clinical uses of a health record with the secondary purpose of a health record, which statement is not true?

The clinical uses of a health record are direct patient care, method of cross discipline education, public health monitoring, and legal document of care

When contacting patients about this breach of confidentiality, Maggie must tell the patients ___________________.

The date of the breach, what happened, and when the breach was discovered

In the video, "Case: Encoder System Update", which of the following statements is true?

The supervisor should have been working with technology support staff to get the coding changes updated by October 1 so they would be ready on time.

A patient's medical record must be accurate and complete. What single source of law governs the content of the medical record?

There isn't a single law

There are significant differences between paper and ESI. Which one of the following is not one of these differences?

There may be more than two volumes to a paper record.

What is the concept of a peer review committee and its duties?

To be charged with the responsibility of evaluating, maintaining, and/or monitoring the quality and utilization of health care services

What is the best description of the general principles of risk management?

To identify areas of operational and financial risk or loss to health care facility and its patients, visitors, and employees; and to implement measures to lessen the effects of unavoidable risks and losses, prevent recurrences of those risks and losses, and cover inevitable losses at the lowest cost

In the video, "HIPAA Compliance Analysis", why would the computer monitors need to be turned away from the public?

To prevent protected patient information from being viewed by the public

How does a health care institution use the data in the National Practitioner Data Bank?

To query a candidate's application for a position on the medical staff

In the video, "HIPAA Compliance Analysis", the HIM director could suggest which of the following in order to correct the HIPAA violations?

Training staff, turning monitors around, and putting patient records away

True or False: Providers may leave a message on a patient's answering machine reminding him/her of an upcoming appointment as long as it doesn't specify type of appointment or the specialty practice.

True

The purpose of a deposition is to

Uncover details of a case.

An organization can refuse to amend medical records:

Under specific circumstances

You send an email to a colleague who has requested information on a surgery your physician performed last year. You attach a file that contains notes on the patient but accidently included information about other patients who were treated in your office. Is this a breach of the Privacy Rule?

Yes

A volunteer at the hospital goes to visit a patient who just had surgery. In an effort to comfort her, the volunteer tells the patient about Mrs. Scardali in Room 222, who also has had surgery, but is making a good recovery. Is this a violation of the Privacy Rule?

Yes, because Mrs. Scardali's information is confidential and should not be disclosed to another patient with her authorization

Will civil or criminal liability apply to a health care institution that destroys a record in other than the ordinary course of business? Why or why not?

Yes, evidence must show that records were destroyed during the ordinary course of business per established protocol and policies.

In the video, "Case: Employee Counseling", did the HIM director incorporate ethical elements in a performance evaluation during the employee counseling?

Yes. The HIM director provided examples of commitment, integrity, and ethical behavior.

Who is covered under HIPAA?

all of the above