Chapter 7

Data, family history, test results, treatments, diagnoses, etc.

Basically, a health record is recorded collection of ___________ on a patient

no, you cannot withhold records due to an outstanding balance

Can health records by withheld pending payment of patient's bills?

Privileged or Confidential

Communication between a physician and a patient is private and legally recognized as what?

False

Communication between a physician and a patient is private but not recognized as privileged T/F

True

Credibility of health record refers to whether the information recorded is believable T/F

yes, in all circumstances

Does an EHR require the same amount of privacy and confidentiality as a handwritten hard copy health record?

True

EHR is a combination of computer hardware and software systems that store patient information T/F

True

Failure to diagnose is the most common allegation in the claims of delayed filing of laboratory tests T/F

the health information technology for economic and clinicial health act

HITECH stands for

credible

Health records must be _________. This means that there can be no alterations, fabrications, or concealments in a record.

state and federal laws

Hospitals and physicians should have a written policy on file detailing staff procedures for release of patient information. The policy must reflect

state and federal laws

Hospitals and physicians should have a written policy on file detailing the procedures for releasing patient information. The policy must reflect what type of law?

True

If changes are made to a health records beyond a reasonable period of time following discharge, particularly after a physician or hospital is on notice of a potential lawsuit, changes in the health record are almost always serious and raise red flags T/F

True

In certain states, legislators have given the patient, the patient's physician, and/or the authorized agent the right to examine or copy health records T/F

Waives

In the typical physician-patient privilege, a physician is prevented from revealing confidential information unless the patient does what to his or her privilege against disclosure?

Court appointed guardian & parents or conservator

Minor patients are typically unable to consent to the release of their health records. Who of the following does not have authority to connect to the release of minor patient's records?

True

Most EHR systems track each entry by user, date, and time. So if a mistake is made and the record needs to be changed, the original error will remain but there will be an addendum with the correct information T/F

independent decision making

Privacy, in the medical setting, involves at least two different kind s of interests. One is individual interest in avoiding disclosure of personal matters. What is the second interest?

to determine the necessity for and quality of health care, for reimbursement, as the standard by which the practice is judged

The health record is increasingly being used:

True

The records of a physician, made in the course of professional office practice, are owned by the physician T/F

True

The subpoena used for health record documents is call subpoena cum laude T/F

Draw a single line through the entry being corrected, date and sign the entry

To correct an entry in a hard copy health record, you should:

No, because the patient should be given an opportunity to transfer the records to a new provider

Upon retirement, can a physician dispose of patient records?

Patients have the right to see their health records .Patient have the right to make corrections. Health records are accessible to the physician and other clinicians

Which statement best describes HIPAA requirements regarding health records stored on the internet?

Ownership carries with it the right and power to exercise authority

Which statement best describes the ownership of health records?

True

While maintaining the record perfectly should always be the goal, incorrect entries may happen. When an error does occur, cross out the mistake, initial and date it, and then write the correct information T/F

err by not disclosing rather than disclosing.

Whin in doubt about releasing medical information, you should:

Patient over the age of majority

Who can consent to the release of health records?

single

With an integrated health record, the patient is represented by a __________ record that includes all outpatient and inpatient activity

HIPAA

____________ allows patients to see their records and make corrections in them

Altering/fabricating

____________ health records modifies the content of the record, while _____________ records means inventing a story.