Content Area X: Health Law
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 REFERENCE: Brodnik, pp 355-364 Green and Bowie, pp 122, 124-125 McWay (2010), pp 96-98, 203 McWay (2014), p 73
A. 7/10/2013 and presented 7/15/2013
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 REFERENCE: Green and Bowie, p 65 LaTour, Eichenwald-Maki, and Oachs, p 37 McWay (2010), p 12 McWay (2014), pp 12, 52, 56-57 Pozgar, pp 25-28
A. Centers for Medicare and Medicaid Services (CMS) formerly known as Health Care Financing Administration (HCFA)
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 REFERENCE: Brodnik, pp 186, 271 (??) Green and Bowie, p 283 LaTour, Eichenwald-Maki, and Oachs, p 313 McWay (2010), p 201 McWay (2014), p 70 Roach, pp 100-101
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.
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 REFERENCE: Brodnik, pp 63-65 (spoilation)
A. Refer request to legal counsel.
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 REFERENCE: Brodnik, pp 244-245, 255 (??) Green and Bowie, pp 291-292 LaTour, Eichenwald-Maki, and Oachs, pp 316-317
A. Request that the personnel office send an authorization for release of information that is signed and dated by the patient
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 REFERENCE: Brodnik, pp 174, 313 Green and Bowie, p 81 Roach, p 494
A. Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required period.
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 REFERENCE: LaTour, Eichenwald-Maki, and Oachs, p 300 McWay (2010), p 201 McWay (2014), p 70
A. When federal and state laws conflict, valid federal laws supersede state laws
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 REFERENCE: Brodnik, pp 355-364 Roach, pp 239-241
A. ask the requester for identification and the request in writing.
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 REFERENCE: Brodnik, pp 87-88 Green and Bowie, p 333 LaTour and Eichenwald-Maki, p 305 McWay (2010), pp 80, 404 McWay (2014), p 64 Pozgar, pp 43-44, 577
A. battery
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 REFERENCE: Brodnik, pp 70-71 Roach, pp 487-488
A. best evidence rule
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 REFERENCE: Brodnik, pp 176-182
A. certificate of authentication
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 REFERENCE: Brodnik, pp 95, 401-402, 467 Green and Bowie, p 267 McWay (2010), p 77 Pozgar, pp 150-152
A. charitable immunity
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 REFERENCE: Brodnik, pp 17, 20 Green and Bowie, pp 265-267 LaTour and Eichenwald-Maki, pp 300-301, 903 McWay (2010), pp 12, 405 McWay (2014), p 50 Pozgar, pp 16-19, 578 Roach, pp 10, 545
A. common law
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 REFERENCE: Brodnik, pp 39-40, 71 McWay (2010), p 52
A. confirm whether or not the record is complete, accurate, and made in the ordinary course of business
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 REFERENCE: Brodnik, pp 165-166 (??) Green and Bowie, p 273 LaTour, Eichenwald-Maki, and Oachs, pp 244, 314 McWay (2010), pp 196-205 McWay (2014), pp 72-73, 274, 441-450 Roach, pp 218-222
A. covered entities provide every patient with its annual business report.
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 REFERENCE: Brodnik, pp 259-260? LaTour, Eichenwald-Maki, and Oachs, p 317 ?
A. dated prior to discharge of the patient
One of the greatest threats to the confidentiality of health data is A. when medical information is used for research or education 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 reviewed as a part of quality assurance activities REFERENCE: Green and Bowie, p 271 McWay (2010), pp 202-208 McWay (2014), pp 71-72
A. disclosure of information for purposes not authorized in writing by the patient.
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 REFERENCE: Brodnik, p 378 Green and Bowie, p 277 McWay (2010), p 301 McWay (2014), p 202 Pozgar, p 330
A. do not require authorization by the patient.
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 REFERENCE: Brodnik, pp 193-194 Green and Bowie, pp 96-97, 349 LaTour and Eichenwald-Maki, p 276 McWay (2010), pp 164-166 McWay (2014), pp 36-139 Roach, pp 49-50
A. ensures records are destroyed and confidentiality is protected
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 REFERENCE: Brodnik, pp 342-343 Green and Bowie, p 292 McWay (2010), pp 181-183 McWay (2014), pp 78, 109 Pozgar, pp 358-559 Roach, pp 352-362
A. insurance companies
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 REFERENCE: Green and Bowie, p 271 McWay (2010), p 81 McWay (2014), p 64 Pozgar, p 52 Roach, pp 406-407, 410 Brodnik, pp 99-100
A. invasion of privacy
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 REFERENCE: Brodnik, pp 333-334 Pozgar, pp 313-314 Roach, pp 89-90
A. minor seeking treatment for breast reduction
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 REFERENCE: Brodnik, p 90 LaTour, Eichenwald-Maki, and Oachs, p 304 Pozgar, p 33
A. misfeasance
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 REFERENCE: Green and Bowie, pp 72-73 LaTour and Eichenwald-Maki, p 312 McWay (2010), pp 194-196 McWay (2014), pp 73-76 Pozgar, p 279
A. patient
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 REFERENCE: Brodnik, pp 66-69 McWay (2010), p 42
A. presiding judge/court
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 REFERENCE: Brodnik, pp 52, 140-146 (??) Green and Bowie, p 93 LaTour and Eichenwald-Maki, pp 274-275 McWay (2010), pp 159-161, 163, 414 McWay (2014), pp 53, 136, 400, 520 Pozgar, p 282 Roach, pp 40-41
A. state and federal governments
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 REFERENCE: Brodnik, p 19 Green and Bowie, pp 265-267 LaTour, Eichenwald-Maki, and Oachs, pp 301, 950 McWay (2010), pp 8-10 McWay (2014), pp 50, 522 Pozgar, pp 16, 19, 582 Roach, pp 6-7
A. statutory law
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 REFERENCE: Brodnik, p 313 Roach, pp 492-495
A. to always follow up by sending the original record by mail
All of the following have laws and regulations addressing medical records EXCEPT A. accrediting agencies B. corporate law C. state laws D. federal laws REFERENCE: Brodnik, pp 156-158 (??) Green and Bowie, p 265
B. corporate law
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 C. 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 REFERENCE: Brodnik, pp 183-184 Green and Bowie, pp 84-85 McWay (2010), p 177 Roach, p 70
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)
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 Ac REFERENCE: Brodnik, pp 155-156 Green and Bowie, pp 10, 320 LaTour, Eichenwald-Maki, and Oachs, pp 151-152, 309-310 McWay (2010), p 161 McWay (2014), pp 68-70 Pozgar, pp 27, 282
B. Health Insurance Portability and Accountability Act
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. Call the patient for a verbal authorization. Request another authorization dated after the discharge date. D. Release the requested information. REFERENCE: Brodnik, pp 168-171 (??) LaTour, Eichenwald-Maki, and Oachs, p 317 McWay (2010), p 204
B. Request another authorization dated after the discharge date
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 REFERENCE: Brodnik, pp 154, 254 Green and Bowie, p 284 LaTour and Eichenwald-Maki, pp 310-311 McWay (2010), p 177 Roach, pp 123-127
B. The information is generated from federally funded research conducted by a private health care organization
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 REFERENCE: LaTour, Eichenwald-Maki, and Oachs, pp 307-308 McWay (2010), p 83 McWay (2014), p 64 Pozgar, p 87
B. a breach of contract
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 REFERENCE: Brodnik, pp 189-190 Green and Bowie, p 94 McWay (2014) pp 53, 136, 400, 520 Roach, pp 43-44
B. age of majority plus the statute of limitations
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
B. coding compliance program that prevents fraudulent coding and billing
In electronic health records, authentication may be achieved by A. handwritten signature B. digital signature C. verbal statement D. all of these REFERENCE: Brodnik, pp 178-179 Green and Bowie, pp 26, 278 LaTour, Eichenwald-Maki, and Oachs, p 87 McWay (2010), p 286 McWay (2014), p 125
B. digital signature
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 REFERENCE: Brodnik, pp 183 Green and Bowie, pp 84-85 McWay (2010), p 157 Pozgar, p 297 Roach, p 70
B. draw a single line through the incorrect information, date and initial the change
All of the following are elements of a contract EXCEPT A. offer/communication B. duty C. price/consideration D. acceptance REFERENCE: Brodnik, p 83 LaTour, Eichenwald-Maki, and Oachs, pp 307-308 McWay (2010), p 5 Pozgar, pp 87-88
B. duty
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 REFERENCE: Brodnik, pp 70-71 LaTour and Eichenwald-Maki, pp 304-305 McWay (2010), pp 71-75 McWay (2014), p 65 Pozgar, pp 33-41
B. health care facility does not have a risk management program.
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 REFERENCE: Brodnik, p. 71 Green and Bowie, pp 270-271 LaTour, Eichenwald-Maki, and Oachs, p 324 McWay (2010), pp 50-51, 409 Roach, pp 383-385
B. hearsay; inadmissible
The ideal consent for medical treatment obtained by the physician is A. expressed B. informed C. implied D. verbal REFERENCE: Brodnik, pp 138-140 Green and Bowie, pp 129, 132, 134 McWay (2010), p 173 McWay (2014), pp 76-77 Pozgar, pp 302-303 Roach, pp 78-81
B. informed
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 REFERENCE: Brodnik, pp 176-177 (??) Green and Bowie, p 275 LaTour, Eichenwald-Maki, and Oachs, p 319 McWay (2010), pp 99, 102, 203-204 McWay (2014), pp 69-75
B. on a need to know basis
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 hospitaloperator paging code blue in room 3 north
B. staff members discussing patients in the elevator
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 REFERENCE: Brodnik, pp 139-141 Green and Bowie, pp 129, 132 McWay (2010), pp 188-189 McWay (2014), pp 76-77 Pozgar, pp 199-200 Roach, p 74
B. the surgeon performing the surgery
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. REFERENCE: Brodnik, pp 158-162 Green and Bowie, pp 129, 132, 134 Roach, p 97
B. the treating physician obtained the patient's signature
The responsiblity of obtaining an informed consent for a surgical or invasive procedure rests with the A. patient B. nurse C. physician D. hospital p. 139 Fundamental of Law, Brodnik
C. physician
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 REFERENCE: Brodnik, p 18 McWay (2010), pp 45-46 McWay (2014), pp 49-50 Pozgar, pp 15-16 Roach, p 2
C. private law
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. REFERENCE: Brodnik, p 148-149 Green and Bowie, p 129 McWay (2010), pp 114, 142, 186-187 McWay (2014), p 77 Pozgar, pp 316-317, 424, 430 Roach, p 97
C. Patient Self-Determination Act
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 REFERENCE: Brodnik, pp 33-34 (??) Pozgar, pp 284-287
C. Remove any information that might prove detrimental to the hospital or physician.
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 REFERENCE: Brodnik, pp 186, 271(??) LaTour and Eichenwald-Maki, p 283 (??)
C. are greater under another applicable federal law, the individual should be afforded the greater access.
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 REFERENCE: Brodnik, p 71 Green and Bowie, pp 270-271 LaTour, Eichenwald-Maki, and Oachs, p 333 McWay (2010), p 51 Roach, pp 383-386
C. business records or exception to hearsay rule
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. contributory negligence. B. respondeat superior. C. corporate negligence. D. general negligence. REFERENCE: Brodnik, p 74 LaTour and Eichenwald-Maki, pp 329-330 McWay (2010), pp 77-78 McWay (2013), p 66 Pozgar, pp 150-152
C. corporate negligence
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 REFERENCE: Brodnik, pp 95, 401 McWay (2010), pp 85, 405 Pozgar, pp 151, 578 Roach, pp 10-11
C. doctrine of charitable immunity
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 REFERENCE: LaTour, Eichenwald-Maki, and Oachs, p 319
C. patient has a direct transfer from the hospital to a long-term care facility.
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 REFERENCE: Brodnik, p 101 Green and Bowie, p 267 LaTour, Eichenwald-Maki, and Oachs, p 304 McWay (2014), p 65
C. duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm
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 REFERENCE: Brodnik, pp 63-65 LaTour, Eichenwald-Maki, and Oachs, p 325 McWay (2010), pp 34-35
C. e-discovery
Traditionally, the medical record is accepted as being the property of the A. patient's guardian B. court C. institution D. patient REFERENCE: Brodnik, p 7 Green and Bowie, pp 72-73 LaTour and Eichenwald-Maki, p 312 McWay (2010), pp 194-196 McWay (2014), pp 73-75 Pozgar, p 279
C. institution
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 REFERENCE: Brodnik, pp 158-159 (??) McWay (2010), pp 215-216
C. is contractually bound to handle confidential information appropriately by means of a signed business associate agreement.
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 REFERENCE: Brodnik, p 92 Green and Bowie, pp 267, 350 McWay (2010), pp 75-76, 414 Pozgar, pp 56, 115-117, 582
C. leaving a foreign body inside a patient
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. REFERENCE: Green and Bowie, p 289 LaTour, Eichenwald-Maki, and Oachs, pp 312-324 McWay (2010), pp 200-201
C. medical examiners or coroners
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 REFERENCE: LaTour, Eichenwald-Maki, and Oachs, p 319
C. release to state workers' compensation agencies
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 REFERENCE: Brodnik, pp 92-93 Green and Bowie, p 267 McWay (2010), p 75 McWay (2014), pp 65-66 Pozgar, pp 56, 115-117
C. res ipsa loquitur
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 REFERENCE: Brodnik, p 21 Green and Bowie, p 257 McWay (2010), pp 12-13, 15, 18, 415 Pozgar, pp18, 1582 Roach, pp 16-18
C. stare decisis.
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 REFERENCE: Brodnik, pp 359-360 McWay (2010), p 209
C. statute or court rules.
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
C. statutes of limitations
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 REFERENCE: Brodnik, pp 37-41 Green and Bowie, p 289 McWay (2010), pp 40-41, 54, 416 McWay (2014), p 77 Pozgar, p 115 Roach, p 317
C. subpoena duces tecum
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 REFERENCE: Brodnik, pp 217, 349 LaTour, Eichenwald-Maki, and Oachs, p 310 McWay (2010), p 177 Roach, p 123
C. veterans' hospitals
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 REFERENCE: Brodnik, p 350 Green and Bowie, pp 284-285 McWay (2010), pp 47, 285, 292 Pozgar, pp 26-27, 279-280 Roach, pp 104-106
D. U.S. Patriot Act
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 REFERENCE: Brodnik, p 218 Green and Bowie, p 285 LaTour, Eichenwald-Maki, and Oachs, p 310 Pozgar, pp 279-280
D. Department of Defense health care facility
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 REFERENCE: Brodnik, pp 14-15 (??) LaTour and Eichenwald-Maki, p 300 McWay (2014), p 50 Pozgar, p 19
D. Constitution of the United States
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 REFERENCE: Brodnik, pp pp 95, 401-402, 467 Green and Bowie, p 257 LaTour, Eichenwald-Maki, and Oachs, pp 329-330 McWay (2010), pp 50-51 Pozgar, p 150
D. doctrine of corporate negligence
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 REFERENCE: Brodnik, pp 295-297 (??) Green and Bowie, p 88 LaTour, Eichenwald-Maki, and Oachs, p 335 McWay (2010), pp 262-263 McWay (2014), p 132 Pozgar, pp 329-330 Roach, p 393
D. Refer this record to the Risk Manager for further review and removal of the incident report
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. REFERENCE: Brodnik, pp 71 Green and Bowie, pp 270-271 McWay (2010), pp 50-51, 409 Pozgar, pp 120-122 Roach, pp 383-384
D. The medical record may be admitted as business records or as an explicit exception to hearsay rule
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 REFERENCE: Brodnik, pp 346 McWay (2010), p 218 Roach, p 301
D. a court order for good cause
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
D. all of the above
HIM professionals have a duty to maintain health information that complies with A. state statutes B. federal statutes C. accreditation standards D. all of these REFERENCE: Brodnik, p 355-364 Green and Bowie, p 273 LaTour, Eichenwald-Maki, and Oachs, p 328 McWay (2010), pp 147, 201 McWay (2014), pp 70-71 Roach, pp 40-41
D. all of these
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 these REFERENCE: Brodnik, p 339 Green and Bowie, pp 284-285
D. all of these
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 these REFERENCE: Brodnik, pp 278-280 Green and Bowie, pp 282-283 LaTour, Eichenwald-Maki, and Oachs, p 188 McWay (2010), pp 289, 291-295 Roach, pp 462-470
D. all of these
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 these REFERENCE: Brodnik, p 278 Green and Bowie, pp 43-48 Pozgar, pp 290-292
D. all of these
Willful disregard of a subpoena is considered A. breach of contract B. abuse of process C. contributory negligence D. contempt of court REFERENCE: Brodnik, p 37 McWay (2010), p 204 McWay (2014), pp 77-78 Pozgar, p 115 Roach, p 322
D. contempt of court
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 REFERENCE: Brodnik, p 35
D. interpretation of documentation in the record
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 REFERENCE: Brodnik, pp 56-57 McWay (2010), pp 34-35 McWay (2014), p 62
D. metadata
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. REFERENCE: Brodnik, p. 358 Green and Bowie, p 288 LaTour, Eichenwald-Maki, and Oachs, p 313 McWay (2010), pp 217-218 Pozgar, pp 323-324 Roach, pp 247-248
D. protected
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 is treated REFERENCE: Brodnik, p 236 Green and Bowie, p 291 LaTour and Eichenwald-Maki, pp 312-324 McWay (2010), pp 207-208
D. the hospital attorney for the facility where the patient is treated
The hospital has a policy that states, "Original medical records may be removed from the Medical Record department jurisdiction only by court order." Which situation would be a violation of the policy? A. a physician wishes to have the record sent to the physician lounge in the OR suite for final signatures B. the Risk Manager requests the record for review by physicians at a quality assurance meeting C. a lawyer has subpoenaed the record for deposition D. the physician has been sued and wants to study the original record at home prior to his deposition
D. the physician has been sued and wants to study the original record at home prior to his deposition
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. REFERENCE: Brodnik, pp 52, 146-147, 149 (??) Green and Bowie, p 94 LaTour and Eichenwald-Maki, pp 276-280 McWay (2010), pp 160-163 McWay (2014), pp 53, 136, 400, 520 Pozgar, pp 282-283
D. the thickness of the records
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 REFERENCE: Green and Bowie, pp 271, 275 McWay (2014), pp 69-75
D. to a family member who is a registered nurse at the facility
