RHIA CH 12-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. 5/09/2013 and presented 1/15/2014 B. 7/10/2013 and presented 7/15/2013 C. 3/10/2013 and presented 5/15/2013 D. 2/15/2013 and presented 1/10/2013

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

A valid authorization for release of information contains A. the date and signature of the patient or the patient's authorized representative. B. all of the choices listed here. C. the name of the hospital or provider who is releasing the medical information. D. the name, agency, or institution to which the information is to be provided.

B. all of the choices listed here.

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. all of the choices listed here. C. locked access to data processing and record areas D. use of unique computer passwords, key cares, or biometric identification

B. all of the choices listed here.

All of the following are elements of a contract EXCEPT A. acceptance. B. price/consideration. C. duty. D. offer/communication.

C. duty.

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

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

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

Constitution of the United States

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

Department of Defense health care facility

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?

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?

Health Insurance Portability and Accountability Act

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

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.

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

Patient Self-Determination Act.

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?

Refer request to legal counsel.

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?

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

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?

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

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.

Request another authorization dated after the discharge date.

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?

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

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. 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?

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.

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?

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

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?

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

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

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

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 breach of contract

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

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

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

U.S. Patriot Act.

In general, which of the following statements is correct? a) when federal and state laws conflict, valid federal laws supercede state laws b)when federal and state laws conflict, valid state laws supercede federal laws c)when federal and state laws conflict, valid local laws supercede federal and state laws d)when federal and state laws conflict, valid corporate laws supercede federal or state laws

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

Courts have released adoption records based on

a court order for good cause.

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

accreditation standards; state statutes; and federal statutes.

The minimum record retention period for patients who are minors is

age of majority plus the statute of limitations.

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

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

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

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

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?

best evidence rule

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

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

corporate negligence

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?

e-discovery

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?

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.

charitable immunity

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

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

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

coding compliance program that prevents fraudulent coding and billing.

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

corporate law

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

common law.

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

consent signed by the patient's parent.

Willful disregard of a subpoena is considered

contempt of court.

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

covered entities provide every patient with its annual business report.

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

institution.

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

dated prior to discharge of the patient.

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

defendant

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

deposition.

In electronic health records, authentication may be achieved by

digital signature.

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

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

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

discovery

Mandatory reporting requirements for vital statistics generally

do not require authorization by the patient.

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

doctrine of charitable immunity.

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

doctrine of corporate negligence

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

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

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

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

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

ensures records are destroyed and confidentiality is protected.

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

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.

hearsay; inadmissible

The ideal consent for medical treatment obtained by the physician is

informed.

A written consent from the patient is required from which of the following entities in order to learn a patient's HIV status? A. spouse or needle partner B. emergency medical personnel C. health care workers D. insurance companies

insurance companies

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?

interpretation of documentation in the record

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

interrogatory.

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

invasion of privacy.

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

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?

leaving a foreign body inside a patient

a published false statement that is damaging to a person's reputation; a written defamation.

libel

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. 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

libel.

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

medical examiners or coroners.

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

metadata.

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

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

misfeasance.

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

negligence.

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. 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?

no consent is needed for emergency care

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

nursing students, medical students, and HIM students.

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

on a need to know basis.

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

patient gives written consent.

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

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

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

patient's diagnosis, patient's address, and patient's name.

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

patient.

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

physician.

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

plaintiff

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

presiding judge/court

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?

private law

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

protected.

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

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?

res ipsa loquitur

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

slander.

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

staff members discussing patients in the elevator

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

stare decisis.

Who determines the retention period for health records?

state and federal governments

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

statute or court rules

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

statutes of limitations.

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

statutory law

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

subpoena duces tecum.

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

the hospital attorney for the facility where the patient is treated.

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

the surgeon performing the surgery

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

the thickness of the records.

Consent forms may be challenged on all the following grounds EXCEPT

the treating physician obtained the patient's signature.

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

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

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

veterans' hospitals