Domain 2 KAHOOT

Can a nursing student review the record of a behavioral health inpatient during clinicals without patient authorization? a) Yes b) No

a) Yes

Do I need a patient's authorization to release information to a spouse for the purpose of continuity of care? a) Yes b) No

a) Yes

The written form of defamation is: a) Libel b) Slander

a) Libel

Which of the following agencies is empowered to implement the law governing Medicare and Medicaid? a) Centers for Medicare and Medicaid Services (CMS) b) Joint Commission c) Department of Health & Human Services d) Institutes of Health

a) Centers for Medicare and Medicaid Services (CMS)

What source or document is considered the "supreme law of the land"? a) Constitution of the United States b) Presidential Power c) Bill of Rights d) Supreme Court decisions

a) Constitution of the United States

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 this case study above, Bayshore Hospital is the ________ in this case. a) Defendant b) Appelle c) Plaintiff d) Appellant

a) Defendant

A 73-year-old male was admitted to 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 day of the facility's attendants. Referring to the case study above, which of the following can the attorney of the resident's family also use as a basis for the lawsuit, and why? a) Doctrine of res ipsa loquitur b) Doctrine of charitable immunity c) Good Samaritan Statutes d) Failure to warn theory

a) Doctrine of res ipsa loquitur

Dr. James is performing a colonoscopy on Dr. Richard. After he examines Richard, he has Nurse T go through the informed consent process with him. Richard is provided an opportunity to ask questions before he signs the form. If Richard suffers an adverse outcome which was not explained during the informed consent process, who will be held responsible? a) Dr. James b) Nurse T c) Richard d) No one. Richard signed the form.

a) Dr. James

In a negligence or malpractice case, all of the following elements must be present in order to shift for the burden of proof onto the defendant EXCEPT the: a) Health care facility does not have risk management program b) Defendant has exclusive control over the instrument that caused injury c) Event would not normally have occurred in absence of negligence d) Plaintiff did not contribute to the injury

a) Health care facility does not have risk management program

The basis for most malpractice lawsuits is: a) Negligence b) Battery c) Defamation of Character d) False Imprisonment

a) Negligence

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 the case study above, given the emergency of the situation, who should the health care provider seek consent from in order to provide treatment to William? a) No consent is needed for emergency care b) Employer c) Patient d) Parents

a) No consent is needed for emergency care

The ownership of the information contained in the physical medical/health record is considered to belong to the: a) Patient b) Physician c) Hospital d) Insurance company

a) Patient

Substance abuse records cannot be re-disclosed a receiving facility to another health care facility unless the: a) Patient gives written consent b) Physician signs DNR form c) Patient expires at receiving facility d) Charge nurse signs the release form

a) Patient gives written consent

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) Clerk of the court c) Subpoenaing attorney d) Defendant

a) Presiding judge/court

Right to be left alone: a) Privacy b) Confidentiality

a) Privacy

What term refers to the wrongful destruction of evidence or the failure to preserve property? a) Spoilation b) Deposition c) Interrogatories d) Litigation triggers

a) Spoilation

Who determines the retention period for health records? a) State and federal governments b) Commercial storage vendors c) Medical staff d) City & state governments

a) State and federal governments

Laws that limit the period during which legal action may be brought against another party are known as: a) Statutes of limitations b) Case law c) Common law d) Summons

a) Statutes of limitations

Internal disclosures of patient information for patient care purposes should not be granted: a) To a family member who is a registered nurse at the facility b) To facility's legal counsel c) On a need-to-know basis d) To attending physician

a) To a family member who is a registered nurse at the facility

Physician refers a patient to a cardiologist and sends patient records. a) Treatment b) Payment c) Healthcare Operations d) None of the above

a) Treatment

Sending a patient's diagnosis to the pharmacy with a prescription. a) Treatment b) Payment c) Healthcare Operations d) None of the above

a) Treatment

Sending a patient's discharge summary from the hospital to the nursing home to which they are transferred. a) Treatment b) Payment c) Healthcare Operations d) None of the above

a) Treatment

A volunteer of a CE is considered part of the workforce. a) True b) False

a) True

An entire NPP must be posted in a clear and prominent location in the facility. a) True b) False

a) True

HIPAA requires each CE to name a Privacy Officer. a) True b) False

a) True

HIPAA requires CEs to provide patients with access to their records within ______ days. a) 15 b) 30 c) 45 d) 60

b) 30

In which instance would you not need informed consent? a) Patient is a minor b) An emergency situation c) Substance abuse treatment d) Patient is incompetent

b) An emergency situation

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) Contributory negligence b) Charitable immunity c) Corporate negligence d) Professional negligence

b) Charitable immunity

The body of law founded on custom, natural justice, and reason, and sanctioned by usage and judicial decision is known as: a) Constitutional law b) Common law c) Statutory law d) Lien law

b) Common law

A CE must agree to a patient's request for amendment. a) True b) False

b) False

Having patients sign in at the front desk is a violation of the privacy rule. a) True b) False

b) False

If an insurance company requires detailed information about the patient's diagnosis for precertification, the CE must obtain patient authorization before providing the PHI. a) True b) False

b) False

Only documents included in the health record are part of the DRS. a) True b) False

b) False

PHI is no longer considered PHI after it has been retained for 50 years. a) True b) False

b) False

The HIPAA Access Control Standard requires biometrics for login. a) True b) False

b) False

The privacy and security rules apply to PHI in any format. a) True b) False

b) False

Under general rules of evidence, a medical/health record is considered ______________ and is _______________ a) Reliable; inadmissible b) Hearsay; inadmissible c) Reliable; admissible d) Hearsay; admissible

b) Hearsay; inadmissible

The ideal consent for medical treatment obtained by the physician is: a) Expressed b) Informed c) Verbal d) Implied

b) Informed

Ms. Jackie Jefferson sustained knee injuries in a car accident that required a visit to the local emergency room. The physician on duty performed a debridement procedure, which required him to remove glass particles from her right knee. However, in performing the procedure, Ms. Jefferson discovered that the emergency room doctor used an incorrect instrument to perform the procedure, which delayed the time frame for treatment. While there is no adverse effects suffered by the patient, Ms. Jefferson nonetheless later filed a negligent claim against the emergency room doctor, which was dismissed. Which of the following elements was not present in order for Ms. Jefferson to recover damages caused by negligence? a) Physician's conduct/action caused harm b) Injury suffered c) Duty of care d) Breach of duty of care

b) Injury suffered

Traditionally, the medical record is accepted as being property of the: a) Patient b) Institution c) Court d) Patient's guardian

b) Institution

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 this case study above, the written answers to questions you have been asked to provide are known as a(n): a) Physical and mental examination b) Interrogatory c) Court order d) Deposition

b) Interrogatory

An interning medical student at the Goodwill Community Hospital accessed several patients' files to obtain their names, DOB, and Social Security numbers, which were used to impersonate patients and file claims with multiple insurance companies in hopes of receiving payment to cover the remaining tuition fees for medical school. This act can be best categorized as: a) A negligent act b) Medical identity theft c) Defamation of character d) Spoilation

b) Medical identity theft

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) Medical record does not belong to hospital b) Medical record may be admitted as business record exception to hearsay rule c) Doctrine of res ipsa loquitur prevails d) Violate physician-patient privilege

b) Medical record may be admitted as business record exception to hearsay rule

All of the following are examples of intentional torts EXCEPT: a) Assault and battery b) Misfeasance c) Defamation of character d) Invasion of privacy

b) Misfeasance

Dr. Sam Vineyard improperly performed a knee replacement surgery, which caused the patient to develop an infection that led to the amputation of the leg and thigh. The best term to describe the action performed is: a) Malfeasance b) Misfeasance c) Nonfeasance d) Malpractice

b) Misfeasance

Dr. Sanders performed a gastrectomy on Mr. Ben due to malignant tumors found on his stomach. Four days after the procedure, Mr. Bean complained of intensifying abdominal pain. A CAT scan revealed a foot-long sponge left inside Mr. Bean's body. Which of the following negligence torts does this scenario depict? a) Nonfeasance b) Misfeasance c) Defeasance d) Malfeasance

b) Misfeasance

Does a consultant need patient authorization to access ER records from the previous month for an audit? a) Yes b) No

b) No

Is a remote coder for FMOLHS considered a business associate? a) Yes b) No

b) No

Is patient authorization required for a physician to provide a DME provider with the patient's diagnosis code? a) Yes b) No

b) No

The hospital outsources janitorial services. Is the janitorial service provider a BA? a) Yes b) No

b) No

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) Durable power of attorney b) Patient self-determination act c) Living wills d) Advanced directives

b) Patient self-determination act

Billing department provides detailed information to insurance company for prior authorization for surgery. a) Treatment b) Payment c) Healthcare Operations d) None of the above

b) Payment

Filing a claim for a colonoscopy with the patient's insurance company. a) Treatment b) Payment c) Healthcare Operations d) None of the above

b) Payment

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 the case study above, Barbara Master is the ____________ in this case. a) Defendant b) Plaintiff c) Appellant d) Appellee

b) Plaintiff

Which two theories of negligence are used to hold health care facilities accountable for the actions of its employees? a) Assault & battery b) Repondeat superior and corporate negligence c) Invasion of privacy & fraud d) Defamation & fraud

b) Repondeat superior and corporate negligence

Deleting a patient's record so it can't be subpoenaed: a) Punitive damages b) Spoliation c) Negligence d) Hearsay

b) Spoliation

Which is more stringent? a) Standards for discovery b) Standards for admissibility

b) Standards for admissibility

Having stringent requirements for password creation is a method of compliance with which type of safeguard? a) Administrative b) Technical c) Physical

b) Technical

All of the following require the patient to sign a consent form EXCEPT: a) For the surgeon to perform surgery b) To release information to the emergency room physician c) To refuse treatment d) For physician to perform an invasive procedure

b) To release information to the emergency room physician

All of the following may present challenges to informed consent EXCEPT: a) Risks and benefits of proposed treatment were not disclosed b) Treating physician obtained patient's signature c) Consent was written in a language that patient could not understand d) Patient was not permitted an opportunity to ask questions

b) Treating physician obtained patient's signature

Ms. Juanita Smith has been hired as the new Health Information Management director at the Sunny Capital City Medical Health System. This organization was created by the merging of two smaller facilities that had hybrid medical records. One of Ms. Smith's first responsibilities is to define what constitutes a legal health record for the Sunny Capital City Medical Health System. All of the following should be considered in developing the definition for the legal health record EXCEPT the: a) Purpose of health record b) Type of software application used for electronic health record c) Standards defining health record content d) State and federal laws

b) Type of software application used for electronic health record

The failure to obtain the written consent of the patient before performing a surgical procedure may constitute: a) Libel b) Contempt c) Battery d) Malpractice

c) Battery

Policies and procedures related to HIPAA are retained for _____ years. a) 5 b) 6 c) 10 d) 50

c) 10

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 the case study above, the sworn verbal testimony you are asked to provide is called a(n): a) Court order b) Physical & mental examination c) Deposition d) Interrogatory

c) Deposition

In electronic health records, authentication may be achieved by: a) Verbal statement b) Handwritten signature c) Digital signature d) Digital signature, handwritten signature, and verbal statement

c) Digital signature

Prohibits discrimination based on genetic information: a) PSDA b) HIPAA c) GINA d) Civil Rights Act

c) GINA

Review of patient records by the physician Peer Review Committee. a) Treatment b) Payment c) Healthcare Operations d) None of the above

c) Healthcare Operations

State licensure surveyor asks to review records of 10 patients with post-op infections. a) Treatment b) Payment c) Healthcare Operations d) None of the above

c) Healthcare Operations

Improper disclosure of patient information to unauthorized individuals, agencies, or news media may be considered a(n): a) Defamation b) Slander c) Invasion of privacy d) Libel

c) Invasion of privacy

The record released on routine request: a) PHI b) Designated Record Set c) Legal Health Record d) Discoverable Record

c) Legal Health Record

Mr. Blake was admitted to All Care Hospital for scheduled cholecystectomy and was discharged within 48 hours. However, after 72 hours following the procedure, Mr. Blake complained of continued intensifying pain in the abdominal region. Mr. Blake was readmitted to the hospital and an x-ray revealed that a sponge had been left within his abdominal cavity. As a result, Mr. Blake filed a lawsuit against All Care Hospital, and his medical records were subpoenaed by the courts. Which of the following documentation should be provided by All Care Hospital in response to the subpoena? a) Personal health record b) Longitudinal health record c) Legal health record d) Medical record excluding x-ray

c) Legal health record

Which of the following is an example of the breach of confidentiality? a) Admission clerk verifying over the phone that the patient is in-house b) Hospital operator paging code blue in room 3 north c) Staff members discussing patients' information in the elevator d) Nurse speaking with the physician in the patient's room

c) Staff members discussing patients' information in the elevator

A medical malpractice claim involving a wrong-site surgery was heard in a higher court, which resulted in the health care facility's requirement to pay the plaintiff $1 million in damages. A similar case with similar elements was also heard in a lower court, and thus the lower court followed the lead of the higher court in deciding the outcome of the case. The term that most appropriately describes the action of the lower court is: a) Writ of certiorari b) Res judicata c) Stare decisis d) Res ipsa loquitor

c) Stare decisis

The doctrine that the decisions of the court should stand as precedents for future guidance is: a) Respondeat superior b) Statue of limitations c) Stare decisis d) Res ipsa loquitur

c) Stare decisis

If a breach involves more than _____ individuals, the Secretary of HHS must be notified immediately. a) 50 b) 100 c) 250 d) 500

d) 500

HIM professionals have a duty to maintain health information that complies with: a) Federal statutes b) State statutes c) Accreditation standards d) All of these answers apply

d) All of these answers apply

Which of the following is considered confidential information if the patient is seeking treatment in a substance abuse facility? a) Patient's diagnosis b) Patient's prognosis c) Patient's name d) All of these answers apply

d) All of these answers apply

Who of the following are permitted to have access to patient health records and information without the patient authorization as part of their training program? a) Medical students b) HIM students c) Nursing students d) All of these apply

d) All of these apply

Ms. Johnson was a diabetic patient and was placed on a strict diet by her primary care physician. However, Ms. Johnson enjoyed baking cakes, and most of all she enjoyed eating slices of her freshly baked German chocolate cakes on a weekly basis, and often neglected taking her medication. As a result, Ms. Johnson suffered a diabetic coma and did not obtain consciousness for two months. She later filed a malpractice claim against her primary care physician. Which of the following is the most appropriate defense the primary care physician should raise in response to Ms. Johnson's claim? a) Gross negligence b) Comparative negligence c) Charitable immunity d) Assumption of risk

d) Assumption of risk

Willful disregard of a subpoena is considered: a) Breach of contract b) Abuse of process c) Contributory negligence d) Contempt of court

d) Contempt of court

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) General negligence c) Respondeat superior d) Corporate negligence

d) Corporate negligence

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 the case study above, what phase of the lawsuit are you involved in? a) Pretrial conference b) Appeal c) Trial d) Discovery

d) Discovery

The proper method for correcting a documentation error in a paper medical record is for the author to: a) White it out, date, and initial the change b) Remove the form from the chart and add a revised form c) Draw an "X" through the incorrect documentation d) Draw a single line through the incorrect info, date, and initial the change

d) Draw a single line through the incorrect info, date, and initial the change

Protects those who render aid at the scene of an accident: a) PSDA b) Informed Consent Law c) GINA d) Good Samaritan Law

d) Good Samaritan Law

Which of the following is needed when a physician conducts an invasive procedure? a) General consent b) Living will c) Advanced directive d) Informed consent

d) Informed consent

The family of Mr. Kent filed a wrongful death lawsuit against Pier Memorial Hospital 10 years after the procedure was performed. In order to avoid the risk of Mr. Kent's electronic medical record being destroyed, a ________ was ordered by the court. a) Resolution waiver b) Subpoena ducus tecum c) Spoilation hold d) Legal hold

d) Legal hold

A breach involving 250 records is discovered on April 1st. The CE must notify the patients by: a) April 15th b) April 30th c) May 15th d) May 30th

d) May 30th

Which of the following does NOT have to be included in informed consent? a) Diagnosis b) Alternative treatment with risks and benefits of each c) Probability that treatment will be successful d) Name of alternative physician who may need to perform the procedure

d) Name of alternative physician who may need to perform the procedure

A 73-year-old male was admitted to 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 day of the facility's attendants. Referring to the case study above, the resident's family brought legal action against the nursing facility for: a) Assault and battery b) Vicarious liability c) Medical abandonment d) Negligence

d) Negligence

Patient's brother needs patient records so patient can apply for disability insurance. a) Treatment b) Payment c) Healthcare Operations d) None of the above

d) None of the above

PHI is: a) Personal Health Information b) Private Health Information c) Patient Health Information d) Protected Health Information

d) Protected Health Information

While performing routine qualitative 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 the situation? a) Tell employees to leave report in record b) Remove incident report from the record and send it to the patient c) Have nursing personnel remove incident report from record d) Refer record to risk manager for review and removal of incident report

d) Refer record to risk manager for review and removal of 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? a) Document in the file folder the total number of pages in the record b) Prepare an itemized list of sheets contained in the medical record c) Number each page of the record in ink d) Remove any info that might prove detrimental to the hospital or physician

d) Remove any info that might prove detrimental to the hospital or physician

Dr. Roberts (orthopedic surgeon) and Nurse Parrish (head nurse on orthopedic surgery unit) have had a hostile working relationship for years. While making rounds on the unit, Dr. Roberts discovered the physical therapy evaluation he 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. Robert'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 the case study above, the oral statement by Nurse Parrish about Dr. Robert's professional practices at the nurses' station can constitute: a) Libel b) Defamation c) Perjury d) Slander

d) Slander

Dr. Roberts (orthopedic surgeon) and Nurse Parrish (head nurse on orthopedic surgery unit) have had a hostile working relationship for years. While making rounds on the unit, Dr. Roberts discovered the physical therapy evaluation he 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. Robert'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 the case study above, the written statement by Dr. Roberts about Nurse Parrish's professional competence in the patient's medical record can constitute: a) Perjury b) Defamation c) Libel d) Slander

d) Slander

A patient has one year after the injury or discovery of the injury to bring a lawsuit. This is an example of: a) Negligence b) Informed consent c) Advanced directive d) Statute of limitations

d) Statute of limitations

Dr. James, a surgeon with Sunnyhill Hospital. Implanted a pacemaker into Mr. Tanner's heart to regulate his irregular heart rate. However, the pacemaker increased Mr. Tanner's heart rate by 30%. It was later discovered that the pacemaker implanted by Dr. James was faulty and a recall had been issued by the m manufacturer. In order for Mr. Tanner to recover damages from the manufacturer, his claim should be based on which of the following? a) Respondeat superior b) Gross negligence c) Ordinary negligence d) Strict liability

d) Strict liability

HIM personnel charged with the responsibility of bringing a medical record to court would ordinarily do so to answer a: a) Personal subpoena b) Judgment c) Deposition d) Subpoena ducus tecum

d) Subpoena ducus tecum

Who is legally responsible for obtaining the patient's informed consent for surgery? a) Medical records personnel b) Nurse c) Admissions clerk d) Surgeon performing the surgery

d) Surgeon performing the surgery

A valid authentication for the disclosure of health information is considered defective if: a) It is addressed to the health care provider b) A description of the purpose is provided c) It is signed by the patient d) The expiration date has passed or expiration event has occurred

d) The expiration date has passed or expiration event has occurred