Final Exam
What is the continuum of care - which services are and are not connected
"Matching an individual's ongoing needs with the appropriate level and type of medical, psychological, health or social care or service." (Primary, secondary & tertiary)
ABC Insurance has requested a copy of Sally Smith's inpatient record to reconcile the documentation in the record with a claim submitted by Sunny View Hospital for $200.00 of laboratory services and $325.00 of radiology services. Upon review of the record, ABC Insurance has determined that the laboratory report does not contain documentation for a laboratory test billed at $50.00. ABC Insurance Company would deny payment for:
$50.00
Hospital-acquired infections
- infections acquired during hospitalizations - usually considered nosocomial when manifested within 72 hours after hospitalizations
Arrange the following numbers in middle-digit order: 01-30-49, 01-31-40, 02-30-49, 02-36-40, 20-39-50, 03-40-50.
01-30-49, 02-30-49, 01-31-40, 02-36-40, 20-39-50, 03-40-50
Arrange the following numbers in terminal digit order: 01-30-49, 01-31-40, 02-30-49, 02-36-40, 20-39-50, 03-40-50.
01-31-40, 02-36-40, 01-30-49, 02-30-49, 20-39-50, 03-40-50
Happy Hospital uses the family numbering system. Tom Short is considered the head of the household and is assigned patient number 01-345678. What numbers would be assigned to his wife and third-born child, respectively?
02-345678, 05-345678
Sunny View Hospital is purchasing new filing equipment. The number of linear filing inches storing current patient records is 1,600. The projected five-year expansion of the files is 600. The shelving unit to be purchased has five shelves with 30 inches of storage on each shelf. How many units are needed?
15
The implementation of standards for sanitation, hygiene, ventilation, and nutrition occurred during the ____ centuries.
17th & 18th
The age of majority in most states is _____.
18 and older
For the month of June there were six newborn deaths and 260 newborn patients. What is the newborn death rate?
2.3%
H and P must be completed within ______hrs
24 Hours
The Joint Commission requires that the history and physical examination be documented in the patient record within ____ of inpatient admission.
24 hours
During the month of May there were 130 births, of which 127 were full-term births and three were premature births. There were five newborn deaths. The newborn death rate is:
3.8%
The Joint Commission requires patient records to be completed ____ days after a patient is discharged.
30
Records become delinquent after _______
30 days; 60 for autopsy
The unit system of numbering is used at Sunny View Hospital. Tom Jones, admitted on January 3, received patient number 345678. The last number assigned by the admitting office was 456788. On February 3, Tom is readmitted. He should be assigned patient number:
345678
The general retention period for HIPAA-related documentation is
6 years
The general retention period for HIPAA-related documentation is __________.
6 years
The privacy rule generally requires documentation related to its requirements to be retained for
6 years
The privacy rule generally requires documentation related to its requirements to be retained for __________.
6 years
An inpatient record is typically between ____ in length.
60 and 100 pages
When staff are instructed to create passwords, it should be recommended that they use __________.
A combination of letters and numbers
A lawsuit has been filed by John Collins, a resident of Virginia, against a hospital in Pennsylvania alleging the wrongful disclosure of a patient's confidential information. This lawsuit could be filed in __________.
A federal district court
Deposition
A formal proceeding by which the oral testimonies of individuals are obtained as part of the discovery process.
Advanced directives
A legal document that specifies an individual's healthcare wishes in the event that he or she has a temporary or permanent loss of competence
Intentional confinement of an individual against his or her wishes may be legally defensible if __________.
A mentally ill patient is a danger to self and others or an individual has a dangerous contagious disease.
An emancipated minor is
A person younger than age 18, living independently
Privacy officer
A position mandated under the HIPAA Privacy Rule—covered entities must designate an individual to be responsible for developing and implementing privacy policies and procedures
Which of the following is not an example of a red flag for a healthcare provider?
A question from a patient about scheduled surgery
Access control
A security measure that defines who can access a computer, device, or network, when they can access it, and what actions they can take while accessing it.
Which of the following statements does the Privacy Rule not require the notice of privacy practices to contain?
A statement that all disclosures will be prohibited from future redisclosures
Statute of limitations
A statutory enactment that places time limits on certain claims
Informed consent
A type of consent in which the patient should have a basic understanding of which medical procedures or tests may be performed as well as the risks, benefits, and alternatives for those tests or procedures.
Tort law addresses a wrong involving all of the following except one?
A wrong against society or public at large
Select the correct sequence of the following names: A. Chris Batts, Andrew C. Batts Sr., Adam Charles Batts, Sister Anne Batts, Andrew C. Batts Jr., A. Douglas Batts.
A. Chris Batts, Adam Charles Batts, A. Douglas Batts, Andrew C. Batts Sr., Andrew C. Batts Jr., Sister Anne Batts
A co-worker is called away for a short errand and leaves the clinic PC logged onto the confidential information system. You need to look up information using the same computer. What should you do?
A. Log your co-worker off and re-log in under your own User-ID and password
The CSP certification if offered by:
ACMCS
The admissions clerk at Tops Hospital is responsible for entering patient registration information into a computerized system, which creates an admission log as well as daily census summaries. She enters the data into the:
ADT System
Which association's code of ethics is more technical in nature, identifying how electronic data should be managed and the expectations of patient privacy?
AMIA
The May 31, 2011 proposed rule introduced the concept of a(n)
Access report
The May 31, 2011 proposed rule introduced the concept of a(n) _________.
Access report
Crystal's request to access her medical record has been denied. The denial is subject to appeal. Which of the following is the most likely reason for the denial?
Access to the PHI would likely endanger Crystal's life or physical safety.
Dr. Roberts is being sued for negligence by one of his patients. Dr. Roberts decides to represent himself as his own attorney. Dr. Roberts is________.
Acting pro se
Regulations written by a state department of health or the US Department of Health and Human Services are examples of __________.
Administrative law
This type of law consists of rules and regulations, issued by agencies that implement statutory law.
Administrative law
The process that allows evidence to be used in a court of law and considered by a jury is________.
Admissibility
The affidavit of the custodian of records allow the health record to be _________.
Admitted into evidence
Which of the following is not an identifier under the privacy rule?
Age 75
Jill has been asked to revise the health record retention policy for her organization. In particular, administration believes the current policy does not properly reflect the length of times that the records of minors should be retained. In conducting her research, Jill refers to the AHIMA best practices for record retention. Based on what she has researched, which of the following should she recommend to administration regarding retention of the health records of minors?
Age of majority plus statute of limitations
A young child is killed by a hit-and-run driver. The case is reported to the medical examiner for all of the following reasons except _____.
Age of the child
Equal Employment Opportunity Commission (EEOC)
Agency of the Department of Justice charged with enforcing Title VII of the Civil Rights Act of 1964 and other anti-discrimination laws
Which statement regarding the patient record is true?
All entries must be legible and complete
If a patient seeks damages as the result of a car accident in which her back was injured, which records would probably be admissible?
All medical records pertaining to her back injury
Barbara Smith claims negligence as the result of misuse of a laser during cosmetic surgery. Which of the following records would be admissible?
All of Barbara's health records pertaining to the laser use during her cosmetic surgery.
In the situation of behavioral healthcare information a healthcare provider may disclose health information on a patient without the patient's authorization in which of the following circumstances?
All of the options are correct
A secretary in the nursing office was recently hospitalized with ketoacidosis. She comes to the health information management department and requests to review her health record. Of the options below, what is the best course of action?
Allow her to review her record after obtaining authorization from her.
St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year-old male has come to the HIM department and requested to see a copy of his medical record. He has told your clerk he was a patient of Dr. Schmidt, a psychiatrist, and was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. As the HIM director, the best course of action for you to take is to
Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient
St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year-old male has come to the HIM department and requested to see a copy of his medical record. He has told your clerk he was a patient of Dr. Schmidt, a psychiatrist, and was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. As the HIM director, the best course of action for you to take is to __________.
Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient
A 22-year-old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's psych ward for the last two months. These records are not psychotherapy notes. Of the options below, what is the best course of action?
Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient.
The professional association that sponsors the Coding Specialist for Payors certification is the:
American College of Medical Coding Specialists
Which organization was founded to improve the quality of care for surgical patients by establishing standards for surgical education and practice?
American College of Surgeons
A waived authorization for a research study may be granted by
An Institutional Review Board
A waived authorization for a research study may be granted by __________.
An Institutional Review Board
assumption of risk
An affirmative defense that bars a plantiff from recovering on his or her negligence claim if defendant proves that the plantiff: had knowledge of danger; understood and appreciated the risks associated with the danger; voluntarily exposed himself or herself to the risks.
Joint Commission
An agency that develops standards for healthcare organizations and certifies healthcare organizations on the basis of adherence to those standards
The director of the HIM department at Sunny Valley Hospital needs to prepare a presentation for the finance committee to convince them to fund an automated MPI system. Which statement would best support her argument?
An automated MPI allows for rapid retrieval of patient information.
A state appellate court will hear a case dealing with an injury to a patient if the attorney appealing the case can prove________.
An error of law occurred
The most common place to find a firewall is between __________.
An organization's internal network and the internet.
When a patient discovers that a hemostat has been left in his abdomen by a surgeon, the patient has a cause of action to bring a lawsuit. To bring suit, the patient must document and serve his allegations to the surgeon. The surgeon must respond via a legal document called a(n) ________.
Answer
Which of the following is not a mechanism to control access to PHI?
Anti-virus software
Which of the following is the intermediate court in the tiered structure of the state court system in nearly every state?
Appellate court
When a dispute is submitted to a disinterested third party and the third party settles the case, this is __________.
Arbitration
With the initiation of HIPAA audits, complaints __________.
Are still used as a way to detect HIPAA violations
Per HIPAA, healthcare operations __________.
Are subject to the minimum necessary requirement
Which category of medical staff would be allowed to perform surgery?
Associate
Which of the following would be the best tool to determine whether or not access to ePHI was appropriate?
Audit trail
You have been given the responsibility of deciding which access control to use. Which of the following is NOT one of your options
Audit trail
Which of the following is not a form of transmission security?
Audit trails
What terms reflect the definition of security supported by the US Code on Information Security?
Availability, Confidentiality, Integrity
In this negligent case, Dr. Smith was found to be 50 percent responsible for the patient's health problem, but the jury also found that the patient was 50 percent responsible for his problem and thus was awarded 50 of the damages. What defense doctrine is applied in this situation?
Comparative negligence
Many states have mandatory reporting requirements for suspected abuse or mistreatment of the following categories of individuals except _____.
Competent adults
Mark Bates has been declared legally incompetent by the court. Mr. Bates' sister has been appointed his legal guardian. His sister is requesting a copy of Mr. Bates' health records. Of the options below, what is the best course of action?
Comply with the sister's request, but first request documentation from the sister that she is Bates' legal guardian.
A conditioned authorization __________.
Conditions treatment, payment and health plan enrollment on an authorization
Which of the following is not a mechanism to detect external medical identity theft?
Conduct a background check on prospective employees
Which of the following is not a mechanism to detect external medical identity theft?
Conduct a background check on prospective employees
This ethical issue involves a clash between personal interests and gain and professional ethics.
Conflict of Interest
The Health Information Technology for Economic and Clinical Health (HITECH) Act has affected HIPAA in which of the following ways?
Consequences to business associate have become greater
Which of the following is not an element that makes information "PHI" under the HIPAA privacy rule?
Contained within a personnel file
Living will
Contains the patient's instructions about the use of life-sustaining treatment.
All of the following are security rule physical safeguard standards except___________.
Contingency planning
A patient is treated in the Emergency Room for severe laceration of the foot. The patient is given written instruction by the physician to have the sutures removed in three days, which the patient fails to do. A severe infection ensues resulting in permanent damage to the patient's foot. The patient sues the surgeon for negligence, and the surgeon uses the ER record to prove __________.
Contributory negligence
The Best Evidence Rule allows for __________.
Copies of records to be allowed as evidence
If a hospital is held liable in its own right for the harm that the physicians on its medical staff caused to a patient, the legal theory being applied is
Corporate negligence
A plaintiff files a lawsuit against a defendant. The defendant, in turn, files a lawsuit against the plaintiff a.) and against a co-defendant b) These two actions, a) and b) are called________.
Counterclaim; crossclaim
Appellate court
Courts that hear appeals on final judgments of the state trial courts or federal trial courts
Hospital that is more than 35 miles from another hospital - has swing beds
Critical Access Hospitals
An error in a paper health record should be __________.
Crossed out so that it can be seen but not relied on.
Reporting of births by state law is allowable for which of the following reasons?
Data are necessary to identify trends.
Which of the following are required components of a HIPAA-compliant disaster plan?
Data back-up, data recovery, and emergency mode of operations
Your organization is sending confidential patient information across the internet using technology that will transform the original data into unintelligible code that can be recreated by authorized users this is
Data encryption (cryptography)
Your supervisor (a physician) is very busy and asks you to log into the clinical information system using her user-ID and password to retrieve some patient reports. What should you do?
Decline the request and refer to the information security policies.
A defendant fails to respond to a plaintiff's complaint. This may result in________.
Default judgment
A tortfeasor refers to which individual in a legal court case?
Defendant
comparative negligence
Defendant is only liable for his share of the injury
Which of the following represents the first step in the Ethical-Decision Making Model?
Define the problem
The admission date and discharge date are considered:
Demographic information
The best source for obtaining primary information on addressing the HIPAA Security Rule would be which of the following sources?
Department of HHS
Helpful University Health System has a laptop sharing program which allows users to request laptop computers to use for short-term projects. Many of the projects involve the use of ePHI. When the laptops are returned to the office, they are often immediately recirculated to another user in the system. This is an example of a violation of which of the following aspects of the security rule?
Device and media controls
Which portion of a security program would ensure that ePHI is not stored on recycled equipment?
Device and media controls
What statement best addresses disclosure of information about abortions?
Disclosed based on required reporting statutes
Judicial decisions may be based on which of the following types of actions?
Disputes between individuals and challenges to the constitutionality of a statute
What is the ethical principle that establishes an obligation to be fair in the apportionment of resources to all patients?
Distributive Justice
Who obtains patient consent
Doctor
The main purpose of an incident report is to do which of the following?
Document adverse events
Beneficience
Doing good or causing good to be done; kindly action
What statement best describes the ethical principle of beneficence?
Doing good, promoting the health and welfare of others
What statement best describes the ethical principle of nonmaleficence? Correct! Doing no harm
Doing no harm
"Public interest and benefit" uses and disclosures under the privacy rule
Don't require the patient's agreement or authorization
"Public interest and benefit" uses and disclosures under the privacy rule __________.
Don't require the patient's agreement or authorization
Nurse Jones takes a telephone order from Dr. Blake. Determine which of the following should occur.
Dr. Blake needs to sign the order within the time period specified by the facility's medical staff bylaws.
Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie's attending physician. Who must sign the history and physical?
Dr. Johns must sign the report first and then Dr. Blake must countersign.
Debbie, an HIM professional, was recently hired as the privacy officer at a large physician practice. She observes the following practices, all of which occur without patient authorization. Which is a violation of the HIPAA privacy rule?
Dr. Lawson gives names of asthma patients to a pharmaceutical company.
Tarasoff v. The Regents of the University of California is a landmark case related to the release of psychiatric patient information without patient authorization. The healthcare provider must release such information based on what circumstance?
Duty to warn
In general, if Virginia and Texas laws conflict:
Each state follows its own law
Examples of tort reform for malpractice actions include all except which one of the following?
Economic and punitive damages
What term best denotes health information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization?
Electronic Health Record
What term best denotes health related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one healthcare organization?
Electronic Medical Record
In some states, if an individual has filed a workers' compensation claim, who may access the individual's health information without the individual's authorization?
Employer's insurer Employer's attorney Patient's employer Employee's attorney
The best mechanism to protect patient information during transit is
Encryption
The best mechanism to protect patient information during transit is __________.
Encryption
The security rule's five sections includes all of the following except___________.
Encryption requirements
National Practitioner Data Bank (NPDB)
Established by the federal Health Care Quality Improvement Act of 1986. It contains information about practitioner's credentials, including previous medical malpractice payment and adverse action history; state licensing boards, hospitals, and other health care facilities access the NPDB to identify and discipline practitioners who engage in unprofessional behavior.
From a business record standpoint, authentication of a record refers to __________.
Establishment of its baseline trustworthiness
The HIPAA Privacy Rule states that required reporting is _____ from the HIPAA Privacy Rule.
Exempt
A plaintiff can establish a strict liability case related to product liability simply by proving which of the following?
Existence of a defective condition without having to establish that the condition was caused by a negligent act.
With regard to marketing, HITECH has __________.
Expanded the scope of the marketing definition
Which of the following disclosures provides an individual with the opportunity to agree?
Facility Directory
Which of the following is most likely to result in a security breach?
Failing to deactivate user access at termination
The negligent tort of nonfeasance refers to which of the following statements?
Failure to do an act that a person is under a duty to do and that a person of ordinary prudence would have done under the same or similar circumstances
A coding and reimbursement specialist collects cancer data from a variety of sources and reports cancer statistics to government and health care agencies.
False
A complication is a preexisting condition that will cause an increase in the patient's length of stay by at least one day.
False
A consent to admission documents a patient's consent for all medical treatment including procedures and surgeries to be completed during the current admission.
False
A consultation report, history and physical exam, and operative report are all types of administrative data.
False
A data dictionary is a standard method for collecting and reporting individual data elements.
False
A lateral file contains shelving with retractable doors and uses side-tab folders.
False
A lateral file resembles a bookshelf and provides twice as much space as an open-shelf file.
False
A medical office manager usually earns a bachelor's degree from a technical college.
False
A unit numbering system requires the retrieval of a patient's record from multiple locations in the filing system when previous records are requested by a physician.
False
AHIMA's coding credentials include the CPC-P.
False
Alphabetic filing expands the files evenly when new records are added.
False
An admission note documented by the attending physician can replace a dictated history and physical examination.
False
An advance directive and an informed consent are considered clinical data.
False
An index is an organized system for the collection and dissemination of information on individual persons who have a particular disease.
False
Associate medical staff members include former members who are honored with emeritus status.
False
Continuous quality improvement plays a role in the quality of clinical elements but not in data quality.
False
Demographic Data is a type of clinical data that identifies a patient's medical condition.
False
Electrocardiogram (EKG) reports include a graphic printout of measurements of the electrical activity of the brain.
False
Fax signatures are not accepted by facilities.
False
Federal agencies are the only organizations that maintain disease registers.
False
Health information personnel who abstract records assign ICD-9-CM/ICD-10-CM codes to diagnoses and procedures.
False
Hospital administrators are responsible for appointing medical staff members.
False
In a unit numbering system, each time a patient is admitted, he or she is assigned a new patient number, but the record is always filed under the original patient number assigned.
False
In a unit numbering system, each time the patient is registered, a new patient number is assigned.
False
In consecutive numeric filing, records are filed in chronological order according to the patient's birth date.
False
In family numbering, the head of household's patient number ends with the digits 00.
False
In middle-digit filing, patient numbers should be limited to nine digits to easily divide the numbers.
False
Incident reports should be filed in the patient record.
False
Information should be entered into a master patient index by various departments to ensure accuracy and to avoid the creation of duplicate records.
False
Master patient index cards are filed by patient number.
False
Medical transcription involves coding of diagnostic information.
False
Middle-digit filing uses three digits in the primary number position.
False
Ready-to-use forms are often more expensive to purchase and therefore are used by few facilities.
False
Registers are primary sources of patient information.
False
Since the early 1980s, the provision of outpatient services has decreased.
False
Soundex is a methodology used to file patient records.
False
Source-oriented records consist of a database, problem list, and initial plan.
False
Student professional practice experiences are usually paid and benefit both the student and the facility.
False
Terminal digit filing divides a nine-digit patient number into three parts.
False
The American Academy of Professional Coders (AAPC) offers the RHIT and Registered Health Information Administrator (RHIA) certification examinations.
False
The American Association of Professional Coders offers the Certified Professional Coder Certification and the Certified Coding Associate Certification.
False
The American Health Information Management Association (AHIMA) and the Centers for Disease Control and Prevention (CDC) offer certification in coding.
False
The CPC and CPC-H credentials are offered through the American Health Information Management Association.
False
The Health Care Financing Administration was created to replace the Centers for Medicare and Medicaid Services.
False
The Health Care Quality Improvement Act of 1986 requires that consumers to be provided with informed consent guidance,and with information about state laws that impact health care decisions.
False
The Health Insurance Portability and Accountability Act (HIPAA) privacy rule prohibits fax transmissions for transporting patient information.
False
The Joint Commission requires that patient records be completed within 20 days after a patient is discharged.
False
The Medical Information Bureau was legislated by the Health Care Quality and Improvement Act of 1986.
False
The National Center for Health Statistics is the federal agency responsible for registration of vital events such as births.
False
The Patient Self-Determination Act of 1990 requires all health care facilities to notify patients age 21 and over that they have the right to have an advance directive.
False
The Uniform Clinical Data Set is collected for ambulatory health care records.
False
The abbreviation ACMCS means the American College of Medical Coding Supervisors.
False
The abbreviation FCS means family care specialist.
False
The appearance of an outpatient to a hospital department is called an encounter.
False
The history of the present illness is the patient's own description of his or her current medical condition.
False
The name of the attending physician is considered patient identification information.
False
The ordering physician is not required to countersign a telephone order documented by a nurse.
False
The physician index is organized primarily by disease codes of patients admitted by physicians.
False
The postpartum record is initiated in the physician's office and includes all tests performed, pregnancy risks, and care given.
False
The primary purpose of the Joint Commission is the mandatory accreditation of health care facilities.
False
The process of translating data into information utilized for an application is data warehousing.
False
The responsibility for gathering information concerning general liability incidents belongs to the utilization manager.
False
Top-tab folders are used for open shelf filing, and end-tab folders are used for lateral cabinets.
False
Which of the following are factors that influence health record retention periods?
Federal and state laws, statues of limitations, and costs of retention.
The Federal Rules of Civil Procedure apply to________.
Federal district courts
Genetic Information Nondiscrimination Act (GINA)
Federal legislation that prohibits discrimination by health insurers and employers based on genetic information
Report for a fetal death would be reported on which required form?
Fetal death certificate
Discharge progress note
Final progress note documented by the attending physician. Includes patient's discharge destination, discharge medications, activity level allowed, and follow-up plan.
The Safe Medical Devices Act requires the reporting of medical device injuries to which agency?
Food and Drug Administration
What is a proprietary Hospital
For-Profit Hospital
Countersignatures
Form of authentication by an individual in addition to the original author of entry.
A defendant does not pay the damages awarded against her in a lawsuit. The court may order the seizure of a portion of her monthly wages to satisfy the judgment in an action called________.
Garnishment
Which of the following is not a HIPAA identifier?
Gender
Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given __________.
General condition and acknowledgement of admission
Emancipated minors _____.
Generally may authorize disclosure of their own PHI
Authenticity pertains to the __________.
Genuinesness of a record
Federal E-SIGN legislation __________.
Gives e-signatures the same legality as handwritten signatures in interstate commerce Facilitates electronic commerce Provides guidance on how records may be stored and retained electronically
Mary Jones stopped to help an individual who was in a car crash. The individual later brought a civil case against Ms. Jones alleging she contributed to injuries the person received at the site of the accident although Ms. Jones had nothing to do with the accident. What defense from liability may Ms. Jones rely on in this situation?
Good samaritan immunity
Ultimate authority in hospital
Governing Board or Board of Directors
Breach notification requirements apply to __________.
HIPAA covered entities, HIPAA business associates & Non-business associate PHR vendor.
The National Practitioner Data Bank (NPDB) was established by the
Health Care Quality Improvement Act
Clinical data
Health information obtained throughout treatment and care of patient. Includes health care information obtained about a patient's care and treatment, which is documented on numerous forms in the patient record.
A nurse witnesses a physician giving an injection to her patient. She is concerned because there is not an order for any injectable in the patient record. She tells the unit clerk about this event. Later, a lawsuit is filed against the physician. Which of the following best describes the unit clerk's testimony?
Hearsay
Healthcare organizations should implement medical identity theft prevention programs because they are __________.
Helpful to protect patient information
Which of the following should be included in the definition of the legal health record?
History and physical
What classification of medical staff membership denies admitting privileges but recognizes the contributions and reputations of its members?
Honorary
When a patient record is composed of paper documents and electronically stored information from numerous clinical systems such as lab, radiology, pharmacy, and nursing, it is referred to as what type of record?
Hybrid Health Record
A medical record that is a mixture of paper and electronic
Hybrid Medical Record
SDBH is a:
Hybrid entity
The state department of behavioral health (SDBH) funds services by private providers throughout the state. It also issues regulations pertaining to the administration of behavioral healthcare throughout the state. It operates five outpatient sites and three inpatient sites around the state. SDBH is a:
Hybrid entity
Susan Clerk works in the admissions office at Hillcrest Medical Center, a large teaching hospital. She would like to obtain a job in the HIM department entering and abstracting data from the disease and procedure indexes for various projects. The hospital offers "minicourses" on a variety of topics. Which course topics would apply to the job she hopes to obtain?
ICD-9-CM/ICD-10-CM and CPT/HCPCS coding
A disease index organizes patient data according to:
ICD-9-CM/ICD-10-CM disease codes
With addressable standards, the covered entity may do all but which of the following?
Ignore the standard since it is addressable
The HIPAA Security Rule allows flexibility in implementation based on reasonableness and appropriateness. This means that covered entities can
Implement based on organizational assessment
The negligent tort of misfeasance refers to which of the following statements?
Improper performance of an act that a person might lawfully do or active misconduct that causes injury to another
Unit numbering
In this system, the patient is assigned a number the first time they are registered and are reassigned the same number for all subsequent admissions encounters.
The designated record set
Includes medical and billing records
The designated record set __________.
Includes medical and billing records
Preadmission testing
Incorporates patient registration, testing, and other services into one visit prior to inpatient admission (or scheduled outpatient surgery) with the results incorporated into the patient's record.
Between 1996 and 2006, the number of ambulatory care visits in the United States has:
Increased
Dr. Jordan, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Smith was the patient's physician. Of the options below what is the best course of action?
Inform Dr. Jordan that he cannot access his daughter's health record without her signed authorization allowing him access to the record.
Dr. Williams is on the medical staff of Sutter Hospital, and he has asked to see the health record of his wife, who was recently hospitalized. Dr. Jones was the patient's physician. Of the options below, which is the best course of action?
Inform Dr. Williams that he cannot access his wife's health information unless she authorizes access through a written release of information.
What term refers to the strategic management of enterprise information, which includes standards, policies, and procedures for access, use, and control of that information?
Information Governance
Which of the following is a public interest and benefit exception to the HIPAA authorization requirement?
Information on domestic violence
A statute of limitations may begin to run when _________.
Injury occurs, injury was discovered, and the injured party reaches the age of majority.
An agency that is heavily involved in combating Medicare and Medicaid fraud is __________.
Inspector general for Health and Human Services
One of the four general requirements a covered entity must adhere to for compliance with the HIPAA security rule is to ensure the confidentiality, ________, and availability of ePHI.
Integrity
Which of the term does the security rule use to define data or information that has not been altered or destroyed in an unauthorized manner?
Integrity
Critical pathways
Interdisciplinary guidelines developed by hospitals to facilitate management and delivery of quality clinical care in a time of restrained resources.
Critical care maps
Interdisciplinary, Outcome measures, Hospitals sometimes consider standing orders, Used for utilization and quality
Which of the following is a potential consequence to the medical identity theft victim?
Intermingling of the victim's and perpetrator's medical information; Insurance denials;Debt collection attempts
Which of the following is a best practice to comply with the revised security provisions of the HITECH Act?
Inventory BAs to determine which Business Associates Agreements need amending.
Although a cause of action for false imprisonment may result if a hospital retains a patient against the patient's will, a hospital may be protected from liability if the patient __________. Is over age 65 Is a danger to himself or others Has not paid his medical bill Has a highly contagious disease
Is a danger to himself or others or has a highly contagious disease.
Medical information loses PHI status and is no longer protected by the HIPAA privacy rule when it
Is de-identified
Medical information loses PHI status and is no longer protected by the HIPAA privacy rule when it __________.
Is de-identified
Which of the following is true about a restriction request?
It can be terminated by either the covered entity or the individual.
Ellen attended a continuing education seminar regarding electronic health records. One of the session speakers emphasized many important points, including which correct fact about the printing of paper documents from an EHR system?
It creates legal challenges as to which document is the source of truth.
Which of the following statements is not true regarding the National Practitioner Data Bank?
It discloses information related to the professional competence of physicians, dentists, and other healthcare practitioners based on authorization from practitioner.
Assessing HIPAA training programs is important for which of the following reasons?
It is how the workforce knows what to do;It is highly visible to auditors.
Shirley Denton has written to request an amendment to her PHI from Bon Voyage Hospital, stating that incorrect information is present on the document in question. The document is an incident report from Bon Voyage Hospital, which was erroneously placed in Ms. Denton's health record. The covered entity declines to grant her request based on which privacy rule provision?
It is not part of the designated record set.
Which of the following is true of health record destruction?
It is permitted pursuant to an approved retention schedule and destruction policy
Which of the following is a reason for not using e-mail to communicate sensitive patient information?
It may be intercepted, The identity of the recipient may be unclear & It may consist of large amounts of data.
Which of the following is true with regard to terminal digit filing?
It provides a high degree of record security.
Since 1951, the organization that has developed professionally based standards to evaluate the compliance of health care organizations is the:
Joint Commission
What ethical principle is violated when a manager does not show fairness to all employees?
Justice
With alphabetic filing, which name is filed first? Polly Kim Kim Barbara Polly Kim Brenda Polly Kim
Kim
Statutory law derives from which branch of the government
Legislative
Mitigation is __________.
Lessening the harmful effects of wrongful use or disclosure of PHI
Which of the following statements is not true regarding the HITECH Act of 2009?
Lessens the scope of privacy and security protections under HIPAA
What is the legal term that refers to the legal obligation or responsibility of Dr. Smith to owe his patient money as a result of a lawsuit the patient has won against Dr. Smith for negligence?
Liability
What type of defamation of character occurs when a false communication is made in writing about an individual?
Libel
Which of the following communicable diseases is typically not required to be reported?
Lice
A competent adult may appoint another person to be his or her personal representative, which gives that person the right to _____.
Make healthcare decisions for the individual Request healthcare information related to the individual Receive information on the mental health of the individual Request information on the personal affairs of the individual
The following reporting exceptions to the doctrine of preemption are allowable except for which of the following?
Marketing
A limited data set:
May be used or disclosed without patient authorization in specific limited circumstances
Information contained in a health record that is discoverable________.
May or may not be admissible
Which joint state and federal program(s) assist(s) with medical costs for those with low incomes and limited resources?
Medicaid
Medical staff bylaws are legally binding and any changes must be approved by a vote of which of the following?
Medical Staff
Medicaid vs Medicare
Medicare = 65 and older Medicaid = For individuals with low income and limited resources
Dr. Harvey has changed a piece of data in a patient record. The information that tracks this change and enables a jury to see this change in a medical malpractice action is called __________.
Metadata
Employees in the hospital business office may have legitimate access to patient health information without patient authorization based on what HIPAA standard/principle?
Minimum necessary
When a state requirement exists that compels a healthcare facility to report patient information and there is an absence of specific data elements required for reporting, what should be disclosed?
Minimum necessary information
Workman's compensation
Money received if you are hurt on the job and can't work for a period of time
What term best describes a set of rules of conduct that are formed through the influence of family, culture, religion, and society? Ethics
Moral Values
The baby of a mother who is 15 years old was recently discharged from the hospital. The mother is seeking access to the baby's health record. Who must sign the authorization for release of the baby's health record?
Mother of the baby
Mr. Jones is suing Dr. Marks for breach of confidentiality in regard to the disclosure of his positive test results related to a sexually transmitted disease. What defense might Dr. Marks claim to counter Mr. Jones claim?
Mr. Jones signed an authorization to disclose his information. Because the test results were positive for a sexually transmitted disease, the results had to be forward to the health department.
A disadvantage of the serial numbering system is that:
Multiple locations must be accessed to retrieve patient records.
Which of the following pieces of information is not typically mandated by state law child abuse reporting requirements?
Name of siblings
Which group recommends review criteria for medical staff membership?
National Association of Medical Staff Services (NAMSS)
Dr. Smith is applying for health care privileges at Hilltop Hospital. As part of the process Sally Jones, medical staff coordinator, needs to obtain information about Dr. Smith's licensure, medical malpractice history, and record of clinical privileges. This information can best be obtained from the:
National Practitioner Data Bank
Printing electronic health records is seen as a _____.
Negative because it raises questions as to the source of truth.
Mrs. Bolton is an angry patient who resents her physicians "bossing her around," refuses to take a portion of the medications that the nurses bring to her pursuant to physician orders, and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient medical record is __________.
Non-compliant and hostile toward staff
The standards of accrediting bodies such as The Joint Commission have the same legal authority as
None of the above (Regulations issued by an administrative agency; A decision rendered by an appellate court; A statute enacted by a legislature)
Lane Hospital has a contract with Ready-Clean, a local company, to come into the hospital to pick up all of the facility's linens for off-site laundering. Ready-Clean is
Not a business associate because it does not use or disclose individually identifiable health information
Lane Hospital has a contract with Ready-Clean, a local company, to come into the hospital to pick up all of the facility's linens for off-site laundering. Ready-Clean is __________.
Not a business associate because it does not use or disclose individually identifiable health information
Securing the authorization of the attending physician, in addition to the patient's authorization, for the release of medical information to the patient's insurance company is
Not legally required
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is
Not protected by the Privacy Rule because it is part of a personnel record
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is __________.
Not protected by the Privacy Rule because it is part of a personnel record
Dr. Blake is selling his practice to Dr. Walton. If he sells patient information as part of the sale of the practice, he is
Not violating HIPAA
Dr. Blake is selling his practice to Dr. Walton. If he sells patient information as part of the sale of the practice, he is __________.
Not violating HIPAA
When a patient is an organ donor whose death is imminent, notifying the family members that the organ procurement organization will be contacted is _____.
Not-required
Common data reported to the medical examiner in cases of reportable deaths typically includes all but which data element?
Number of children
The newborn death rate is calculated by dividing the number of newborn deaths by _____ and multiplying by 100.
Number of newborn patients
The premature newborn death rate is calculated by dividing the _____by the number of premature newborn patients and multiplying by 100.
Number of premature newborn deaths
Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication?
Nurse working on the unit where the patient is located
Sunny Valley Hospital uses the SOAP structure to document patient information. Observations about the patient would be documented in the ____ section of the progress note.
Objective
What statement best describes the ethical principle of justice?
Obligation to be fair in the distribution of benefits and risks
Organization that monitors for fraud and abuse in Medicare system
Office of the Inspector General
Which of the following facilities must report information about implantable cardiac defibrillators?
Only hospitals seeking reimbursement
The heath information management (HIM) department has purchased end-tab folders and is now selecting file equipment. Which type of file equipment should be purchased?
Open shelf files
Forms of evidence include __________.
Oral testimony, written documents, pictures and objects.
Which of the following is a "public interest and benefit" exception to the authorization requirement?
PHI regarding victims of domestic violence
Which of the following techniques would a facility employ for access control?
Passwords
You have been asked to provide examples of technical security measures. Which of the following would NOT be included
Passwords Training
Physician-patient privilege belongs to the __________.
Patient
Which of the following exemplifies an acceptable patient record entry?
Patient ambulated 30 feet
Alphabetic filing rules
Patient's last name, first name, and middle initial are used to file patient records (when no numbering system is selected for use by the facility)and to file master patient index cards (when a numbering system is used by the facility).
Amendment to PHI
Patient's written request to correct, amend or change an existing medical record.
Per the HIPAA Privacy Rule, a hybrid entity is defined as one that
Performs both covered and non-covered functions under the Privacy Rule
Per the HIPAA Privacy Rule, a hybrid entity is defined as one that __________.
Performs both covered and non-covered functions under the Privacy Rule
Security awareness training programs require the implementation of awareness and training of all workforce members and should include___________.
Periodic security reminders
In general, reviews for compliance with various aspects of the security rule should be conducted___________.
Periodically
What term best denotes health related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual?
Personal Health Record
Which of the following information is not included about a physician in the National Practitioner Data Bank?
Personal bankruptcy
Mr. Green won a $500,000 lawsuit against Dr. Blue. Dr. Blue has appealed. Upon appeal, Dr. Blue is referred to as the________.
Petitioner
Health records may be admitted into evidence in which of the following cases?
Physician negligence, competency hearings, and criminal misconduct.
Sunny Valley Hospital uses auto-authentication for transcribed records. Which of the following would apply?
Physicians enter a unique identifier before a report is transcribed.
A principle of law that serves as a guide in similar subsequent cases is called __________.
Precedent
Ms. RHIT is writing a policy for filing alphabetic records. Which statement below should be included in the policy?
Prefixes included as part of the patient's last name are filed alphabetically.
The adoptive parents of Susan, a minor, wish to access her health record. What is the best way for them to obtain a copy of Susan's operative report?
Present an authorization that at least the mom or dad signed
A patient's entry to the health care system in most nonemergency situations - which include health maintenance and coordination of referrals - is called ____ care.
Primary
Dr. Jones examines Sally Sick in the office and completes a history and physical exam for the treatment of an upper respiratory infection. Dr. Jones writes a prescription for antibiotics and instructs her to return to his office in 10 to 14 days. This is classified as a(n) ____ care service.
Primary
When developing security procedures for remote workforce, the HIM director should reference which of the following?
Privacy and security rules, state statutes and other federal statutes
Which type of law, public or private, applies to a lawsuit by a patient against a physician and the practice this physician co-owns?
Private
If an individual is pulled over by a police officer for what appears to be impaired driving and the individual is required to provide blood samples for testing of blood alcohol content, this represents an exception to which of the following?
Privilege
A plaintiff's attorney has filed a state-law complaint in federal court. This is an error of what nature?
Procedural law
Principle procedure
Procedure performed for definitive or therapeutic reasons, rather than diagnostic purposes, or to treat a complication, or that procedure which is most closely related to the principal diagnosis
Integrated progress notes
Progress notes documented by physicians, nurses, physical therapists, occupational therapists, and other professional staff members are organized in the same section of the record. Allow the patient's course of treatment to be easily followed because a chronological "picture" of patient information is presented.
Trauma registry data is used for all of the following purposes except
Prosecution of drunk drivers
Trauma registry data is used for all of the following purposes except _____.
Prosecution of drunk drivers
Apology statutes __________.
Protect providers' apologetic communications to patients from being admitted into evidence.
The HIPAA Security Rule requires which of the following to achieve compliance?
Protecting ePHI
Which of the following is not a purpose of the health record?
Provide proof of services for reimbursement, serve as a legal document, and serve as a communication tool among providers.
Rehabilitation facilities
Provides occupational, physical, and speech therapy to patients with various injuries and various neurological and neuromuscular conditions
Consultation
Provision of health care services by a consulting physician whose opinion or advice is requested by another physician.
Which of the following involves the government as one of the parties?
Public law and criminal law
James Jones is scheduled for outpatient surgery on July 15. He undergoes preoperative testing on July 3 and is assigned patient record number 234567. He undergoes outpatient surgery on July 15 and is assigned patient record number 334789. On October 10, he is admitted as an inpatient and assigned patient record number 435679. His record is filed in three different locations. The system being used is:
Serial numbering
Tom Jones is admitted to Sunny View Hospital on February 3 and assigned patient number 123456. One year later, he is readmitted and assigned number 133890. The patient record from the folder labeled 123456 is renumbered as 133890 and filed in the newly created folder (also numbered 133890). Folder 123456 remains in the filing system with a note indicating the new patient number. The system being used is called:
Serial-unit numbering
The Medicare Conditions of Participation __________.
Set forth health record content requirements
Which of the following types of abuse and neglect of the elderly is required to be reported?
Sexual, physical and emotional
Which statement best describes the right of a mother about the reporting of her child's birth?
She may request an account of the disclosure about the birth.
National Practitioner's Data Bank
Shows doctors license status & other info; need to update data entries.
A countersignature __________.
Signifies review of a first provider's actions and documentation
What type of defamation of character occurs when a false oral communication is made about an individual?
Slander
Terrace View Hospital is located in a community that has a large population of Hispanic and foreign patients. Which system can help facilitate the organization of the master patient index?
Soundex
When Dr. Smith realized he was being sued over a malpractice issue, he intentionally destroyed certain records and other evidence relevant to the legal proceedings. What legal concept is indicative of this situation?
Spoliation
What legal concept maybe applied when Dr. Smith failed to prescribe the appropriate treatment for a patient that would have been prescribed by any other physician in a similar situation treating a patient with a similar condition?
Standard of Caree
If a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be followed in determining this case is __________.
Stare decisis
Healthcare facilities are required to report vital statistics to which of the following authority?
State department of health
Responsibility for completing a fetal death certificate is determined by
State law
Minors are basically deemed legally incompetent to access, use, or disclose their health information. What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors?
State law because HIPAA defers to state laws on matters related to minors
Patient-provider privilege is defined by __________.
State laws
When determining which immunizations must be reported, which of the following would you refer to first?
State reporting requirements
Substance abuse patient information is afforded federal protection through HIPAA and Alcohol and Drug Abuse Regulations. If a minor wishes to authorize release of his or her health information he or she may do so if _____.
State statute allows the minor to authorize release State statute allows minor and parent to authorize release
Under the privacy rule, the following must be included in a patient accounting of disclosures:
State-mandated report of a sexually transmitted disease
Ms. HIM files the following records: 223345, 223346, 223347, 223348, and 223349. Which system is being used?
Straight numeric filing
Which of the following can the HIM department require of a patient who is requesting an amendment to her PHI?
Submit the request in writing
Examples of reportable deaths include which of the following?
Sudden, unexpected, violent, suspicious
The Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) __________.
Supports the admissibility of reproductions into evidence with stipulations.
When a legal hold is issued by the court, what action must an organization take?
Suspend the processing or destruction of the records in question
Serial numbering system
System where a patient is issued a unique numerical identifier for every encounter at the healthcare facility; if a patient is admitted to the healthcare facility five times he or she will have five different health record numbers
Sunny View Hospital is part of a large university hospital with a very active and congested file area. Records are filed and refiled throughout the day. Which filing system should be used to distribute the records equally in the file area?
Terminal Digit
Ms. HIT files the following records: 13-40-05, 14-40-05, 14-41-05, 15-41-05, and 16-41-05. Which system is being used?
Terminal digit Filing
Organization that has jurisdiction over public health, welfare and civil rights
The Department of Health & Human Services
Which organization currently provides voluntary accreditation of health care organizations?
The Joint Commission
The Kids' Foundation, a foundation related to Children's Hospital, is mailing fundraising information to the families of all patients who have been treated at Children's in the past three years. Based on the facts given, which of the following are true?
The Privacy Rule was not violated as long as the fundraising activity was not based on the patients' diagnoses & Children's Hospital must have notified the patients or patients' guardians of this potential use in the notice of privacy practices
Augusta Clinic has requested that Furr Hospital send its health records from Helena Smith's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true?
The Privacy Rule's minimum necessary requirement does not apply.
A legal matter was tried at the district court level and appealed to a federal appellate court. The case is now being appealed to the United States Supreme Court. Which of the following statements is the most correct?
The US Supreme Court will likely deny cert and decline this case for oral argument
A health information management professional may attend legal proceedings and testify as to ________.
The authenticity of the patient's health record
When comparing the HIPAA-defined designated record set with the legal health record, which of the following is correct?
The designated record set is wider in scope than the legal health record.
When ownership of a physician practice changes, __________.
The health records of the practice may be transferred as assets
Linda Wallace is being admitted to the hospital. She is presented with a "Notice of Privacy Practices." In the notice, it is explained that her PHI will be used and disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she does not want her PHI used for those purposes. Which of the following is true?
The hospital is not required to honor her wishes.
Under HIPAA, a covered entity may deny a patient's amendment request for which of the following reasons?
The information is accurate and complete; the information in question was not created by this covered entity; the information is not part of the individual's designated record set.
Evidence is __________.
The means by which facts of a case are proved or disproved.
The Privacy Rule permits charging patients for labor and supply costs associated with copying health records. Mercy Hospital is located in a state where state law allows charging patients a $100 search fee associated with locating records that have been requested.
The privacy rule will preempt state law in this situation.
Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true?
The privacy rule's minimum necessary requirement does not apply.
Utilization review manager
The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organization's utilization management plan.
Which of the following is true regarding breaches and breach notification per HITECH?
There are exceptions to the breach definition, and notification is therefore not required.
Which of the following statements is true regarding privacy of health information?
There is no US Constitution right of privacy; Privacy protection has been established by Federal & state laws
Which of the following must notify the Federal Trade Commission of a breach?
Third-party service providers of PHR vendors
The HIPAA Security Rule allows flexibility in implementation based on reasonableness and appropriateness.
This means that covered entities can Implement based on organizational assessment
One or more advantage(s) of arbitration over utilizing the court system to resolve a dispute is(are) __________.
Time savings, cost savings, increased privacy
Which medical staff committee is responsible for the review of preoperative and pathologic diagnosis to determine the necessity of surgery?
Tissue Review
The privacy rule resides in __________.
Title II of HIPAA
The role of the Ethics Committee in a healthcare organization is __________.
To analyze ethical problems and suggest responses
Which of the following reasons bestdepicts why HIPAA was enacted?
To protect patient information as a result of increasing use of information technology in healthcare
Which of the following terms denotes a civil wrongdoing for which the law will provide a remedy in the form of a law suit to recover damages?
Tort
The Federal Rules of Civil Procedure address
Trials, Federal district court procedures, and filing of a lawsuit.
A cancer registrar is a health care professional who has primary responsibility for ensuring the timely, accurate, and complete collection and maintenance of cancer data.
True
A case manager is responsible for coordinating patient care to ensure timely discharge or transfer of patients.
True
A claims examiner reviews health-related claims to determine whether the costs are reasonable and medically necessary.
True
A consultation includes the examination of a patient by a specialist, who also provides an opinion or advice.
True
A data set represents a standard method for collecting and reporting individual data elements.
True
A delinquent record can result in suspension of a physician's medical staff privileges.
True
A discharge progress note can be documented in a patient record instead of a discharge summary if a patient had an uncomplicated hospital stay of less than 48 hours.
True
A health insurance specialist reviews health-related claims to determine whether the costs for health care services are reasonable, and to determine medical necessity.
True
A licensed nurse is required to have a public license to deliver care to patients.
True
A listserv is an Internet-based or email discussion that covers a variety of topics and issues.
True
A living will is a written document that informs a health care provider of a patient's desires regarding life-sustaining treatment.
True
A manual master patient index (MPI) is less expensive to purchase compared with an automated MPI.
True
A patient record serves as a business record for the patient encounter and contains administrative and clinical data.
True
A principal procedure is performed for definitive or therapeutic reasons.
True
A privacy officer oversees activities that relate to the development, implementation, maintenance of, and adherence to the organization's policies and procedures covering privacy of and access to patient health information.
True
A registry is used to collect and sort data, and to perform statistical analysis and study.
True
A serial numbering system does not require computer software to track the assignment of patient numbers.
True
A signature legend identifies the author of a record entry by full signature when initials are used in the patient record.
True
A wide-area network includes computers that are placed far apart and connected by telephone lines.
True
AHIMA requires Registered Health Information Technicians (RHITs) to submit proof of 20 continuing education hours every two years.
True
Abstracted patient information is used to generate diagnosis and procedure indexes.
True
Administrative data includes demographic, socioeconomic, and financial information.
True
All ancillary reports should be filed in the patient's record within 24 hours after interpretation of test results.
True
All orders must be authenticated by the responsible provider.
True
Alphabetic filing systems are easy to learn, and staff can be trained quickly.
True
American Osteopathic Association (AOA) requirements state that a patient record must be maintained for each patient treated in the emergency department.
True
An admission/discharge/transfer (ADT) system is interfaced with an automated MPI to input patient registration information.
True
An automated master patient index consists of a computerized database of identification data about patients who have received health care services from a facility.
True
An initial plan describes the actions that will be taken to evaluate, treat, and educate the patient about his or her current condition.
True
At the time of admission, the patient or patient representative often signs an admission consent form to consent to treatment.
True
Automated case abstracting systems allow facilities to calculate prospective payment system reimbursement.
True
Breach of patient confidentiality can result in termination from a professional practice site.
True
Case mix analysis is the study of types of patients treated by a facility.
True
Centralized filing systems require additional staff to handle the filing and retrieval of records.
True
Chart tracking systems help to control the file area and facilitate accurate filing.
True
Coding is the assignment of numbers to diagnosis, services, and procedures, based on patient record documentation.
True
Color coding allows misfiles to be easily identified.
True
Computer systems have changed the functions and role of health information professionals.
True
Continuous quality improvement (QI) plays an important role in data quality.
True
Data is reliable if it is consistent throughout all systems in which it is stored, processed, and/or retrieved.
True
Demographic data is documented on the face sheet of a manual patient record.
True
Every report in the patient record must contain patient identification data.
True
Filing controls are established to ensure accurate filing and timely retrieval of patient records.
True
Health care providers are responsible for documenting care and treatment to prove that patient care was provided.
True
Hospital-originated infections are also known as nosocomial infections.
True
In 1918, just 89 of 692 hospitals surveyed as part of the Hospital Standardization Program met requirements of the Minimum Standard for Hospitals.
True
In a family numbering system, each family member is given a two-digit modifier that serves as a prefix (or suffix) to the household patient number.
True
In consecutive numeric filing, records are filed in strict chronological order according to patient number.
True
In serial numbering, a patient receives a new number each time he or she is admitted.
True
Indexes and registers allow health information to be maintained and retrieved for the purposes of education, planning, and research.
True
Individual state laws require health care facilities to obtain licenses to operate from state departments of health.
True
Inpatient coders usually obtain CCS certification, while physician office coders choose CCS-P and/or CPC certification.
True
Inpatient record creation may begin prior to admission, when preadmission testing is performed.
True
Integrated progress notes are documented by physicians, nurses, therapists, and other professionals in the same section of the patient record.
True
Many medical transcriptionists work at home using the Internet.
True
Medical assistants perform routine administrative and clinical tasks such as answering telephones and scheduling appointments.
True
Medical transcriptionists are credentialed by AHDI.
True
Medicare Conditions of Participation (CoP) categorize outpatient care as optional hospital services and require the hospital to maintain a medical record for each outpatient.
True
Medicare Conditions of Participation require hospitals to retain medical records for a period of no less than five years.
True
Most facilities organize the patient record according to reverse chronological date order during inpatient hospitalization.
True
Most hospital statistics are collected using automated computer systems.
True
Only authorized personnel should have access to file areas, and the file area should be secured when a file staff member is not in the file area.
True
Outguides are beneficial in locating records that have been removed and are unreturned.
True
Patient records are filed in one location in the filing system when a unit or serial unit numbering system is used.
True
Persons under 18 years of age must have their parents' or guardian's consent to donate organs.
True
Pre-and post anesthesia progress notes are often documented on a separate form to facilitate documentation by the anesthesiologist.
True
Preadmission testing on an outpatient basis is more frequently performed than is admitting patients a day or two early to perform such tests.
True
Privacy officers assure that an organization's policies and procedures covering covering privacy of and access of patient health information are in compliance with federal and state laws.
True
Progress notes facilitate health care team communication, which is crucial to quality care.
True
Sally Slip fell and broke her arm. Her fracture would most likely be treated by an orthopedic specialist.
True
Social Security numbering systems are used in Veteran Affairs medical centers.
True
Terminal digit numbers are usually written with a hyphen separating each part of the number.
True
The American College of Surgeons (ACS) improved the quality of care for surgical patients by establishing standards for surgical.
True
The Centers for Disease Control and Prevention is a federal agency that requires the reporting of information about diseases.
True
The Health Care Financing Administration is now called the Centers for Medicare and Medicaid Services.
True
The Joint Commission standards require a patient's consent to treatment, and require that the record contain evidence of consent.
True
The National Center for Health Statistics developed a standard certificate of birth that states adopt for their use.
True
The Uniform Rules of Evidence states that for a record to be admissible in a court of law, all patient record entries must be dated and timed.
True
The admitting diagnosis is the condition or disease for which the patient is seeking treatment.
True
The death certificate is usually filed with a state department of health's office of vital statistics within five days
True
The drug utilization review committee is responsible for maintaining the hospital formulary.
True
The forms committee oversees the process of new forms control and design.
True
The legibility of patient record entries impacts patient care.
True
The medical record is the property of the provider.
True
The number of inpatients present at census taking time is called the daily census count.
True
The pathology report assists in the diagnosis and treatment of patients by documenting analysis of tissue removed surgically.
True
The patient history documents the patient's chief complaint, history of present illness, past/family/social history, and review of systems.
True
The primary purpose of the patient record is to provide continuity of care.
True
The purpose of contracting out health information services is to improve quality and contain costs.
True
The role of a forms committee is to review all proposed forms to be used in the patient record.
True
The utilization review process was strengthened through formation of professional standards review organizations (PSROs) to monitor the appropriateness, quality, and outcome of services provided to beneficiaries of Medicare, Medicaid, and Maternal and Child Health programs.
True
There are no universally accepted rules for filing alphabetic records.
True
Third-party payer information is classified as financial data, and it is obtained from the patient at admission.
True
Upcoding or maximizing codes is considered DRG creep.
True
When a facility closes, it is the responsibility of the closing facility to ensure that records are handled according to federal and state statutes.
True
When an individual is admitted as a hospital inpatient, past records are frequently retrieved to provide for continuity of care.
True
Security Scenario #2 You are a research nurse coming off of a double shift at the hospital and a physician asks you to fax a patient's lab test results to his office fax. The results are ready but it is after hours in his office and none of the office staff are available to receive the fax.
Unacceptable
The minimum core data set used to collect information on individual hospital discharges for the Medicare and Medicaid programs is called the:
Uniform Hospital Discharge Data Set
Rebecca Brown was born at Mercy Hospital in 1967 and assigned patient number 576890. She was admitted in 1974 for a tonsillectomy and reassigned number 576890. All of her admissions are filed in a single folder. The system being used is:
Unit numbering
The collection of federal statutory law is __________.
United States Code
Which of the following occupies the highest hierarchical position?
United States Department of Health and Human Services
Mrs. Rollins was admitted to University Hospital by Dr. Connor. Mrs. Rollins' hospital bill will be paid by Blue Cross Insurance. Upon discharge from the hospital, who owns the health record of Mrs. Rollins?
University Hospital
Which of the following is a good policy for faxing PHI?
Use a cover sheet with a confidentiality statement
Based on the "Red Flags Rule," entities are considered creditors if they __________.
Use consumer reports in connection with credit transactions , Furnish information to consumer reporting agencies , Extend credit
Based on the "Red Flags Rule," entities are considered creditors if they
Use consumer reports in connection with credit transactions ;Furnish information to consumer reporting agencies ;Extend credit
Per the Privacy Rule, which of the following requires authorization for research purposes?
Use of Mary's individually identifiable information related to her asthma treatments
Admission-discharge-transfer (ADT)
Used to input patient registration information, which results in creation of an automated master patient index database that allows for the storage and retrieval of the information.
Which of the following is the public or known portion of most user log-ins?
User ID
This ethical theory focuses solely on the expected outcome.
Utilitarianism
You make an ethical determination based on what is beneficial to the greatest number of people
Utilitarianism
Suzy Staff's job responsibilities include coordinating patient care to ensure that patients receive timely discharge or transfer. Her job title is:
Utilization manager
During the flu season, a nursing home reports the cases of known flu in the nursing home population. The local health department calls and wants more information on the recent hospitalizations of these flu patients. How should the request be handled?
Verify the authenticity of the request and provide information.
This ethical theory focuses on the idea that healthcare professionals select their profession because they possess a desire to do good.
Virtue-based ethics
Most hospitals in the United States are ____ and are operated by religious or other charitable groups.
Voluntary
A patient places her medical condition at issue by filing a lawsuit against her treating physician. By doing this, the patient has __________.
Waived the physician-patient privilege
Severity of Illness and Intensity of Service
What Utilization Review Looks for
Under which of the following conditions is the patient's authorization required for the use or disclosure of medical information?
When a patient's life insurance company requests the information
A physician practice was warned last year by auditors that its disposal of paper records (dumping them in bins without shredding or deidentifying them) violated HIPAA, but it did nothing to correct the problem. When the records were found in a city dumpster, an anonymous caller notified the Office for Civil Rights (OCR). An investigation by OCR confirmed that the practice had been warned about the violations. What level of violation is OCR likely to assess in this situation?
Willful neglect, uncorrected
Disabling the USB drive on a computer is an example of what type of security?
Workstation
Which computer virus stores and replicates itself?
Worm
Tortfeasor
Wrongdoer, defendant
Over a 24hour time period a large number of individuals have arrived in the emergency department of a local hospital complaining of severe abdominal pain, vomiting, and diarrhea that they have all seemed to pick up at a local restaurant in town. The hospital has provided the public health department with the PHI of all patients treated for the illness. Did the hospital have the right to disclose this information?
Yes, the hospital may disclose PHI to a public health department if state law does not specifically require it if the disclosure is for controlling the spread of disease.
Summons
a document that gives the defendant notice of the lawsuit and explains the defendant's procedural obligations
Master Patient Index (MPI)
a patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilities patient identification, and assists in maintaining a longitudinal patient record from birth to death
Procedural due process may apply to
a physician's medical staff membership at a hospital disciplinary action taken against an HIM employee
Subpoena duces tecum
a subpoena instructing the recipient to bring documents and other records to a deposition or to court
When the HIM professional is considering the major departmental functions to include in a disaster plan for emergency operations, which of the following would be the least important?
a.) Billing
Integrity refers to the __________.
accuracy and completeness of information
The HIM director is writing a policy to ensure the accuracy of an automated MPI. The two departments that should be allowed to enter or update information in the master patient index are:
admissions and health information
Sunny Valley Hospital uses the serial numbering system. The master patient index card should contain:
all the numbers issued to the patient
Contributory negligence
an individual's conduct contributed in part to the injury that the individual suffered
An Internet-based third-party entity that manages and distributes software-based services across a WAN from a central data center is known as a(n) ____ provider.
application service
Sunny Valley Hospital has an electronic health record system. The health information management (HIM) department has been asked by the quality management department to monitor the number of times that providers make corrections in patient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions?
audit trail
A security procedure that causes a computer session to end after a predetermined period of inactivity is a(n)
automatic log-off
When data is displayed along an X-axis and a Y-axis, a _____ is used:
bar graph
A deposition
can be used to impeach a witness at trial
Respite care
care provided by specially trained individuals at a setting other than the patient's home to offer relief and rest to primary caregivers.
The HIM department is responsible for generating reports and statistics on the types of patients treated by the facility. This function is called:
case mix analysis
In the federal court system, appellate courts are called
circuit courts
The collection of federal statutes is found in a(n) __________.
code
A preexisting condition that causes an increase in the patient's length of stay by at least one day in 75% of the cases is known as a:
comobidity
Active physicians on a hospital medical staff have an obligation to perform which of the following duties?
complete records in a timely manner, treat patients regardless of ability to pay, & serve on medical staff committees
The exchange of data among multiple software products is known as:
computer interface
A form of authentication by an individual in addition to the signature by the original author is known as a(n):
countersignature
To ensure compliance with the HIPAA security rule training requirement, the HIIM Director should do which of the following?
determine special needs of HIM staff and provide training
Which is an example of clinical data?
diagnosis
A common item not found on an admission data entry screen is the:
discharge diagnosis
The QI department needs to obtain a list of patients discharged within the last three months with a diagnosis of diverticulitis. This information can be obtained from the:
disease index
The workforce security administrative safeguard requires policies and procedures that
ensure appropriate ePHI access by workforce members;prevent access to ePHI by workforce members who should not have access
Diversity jurisdiction refers to the ability to bring a legal action in a
federal district court
The legal health record must meet standards as defined by:
federal regulations, state laws, and accreditation boy standards.
The name, address, and phone number of the third-party payer is considered:
financial data
Initials of care providers are typically used to authenticate entries on:
flow sheets and medication records
Which of the following is ultimately responsible for the quality of care in a hospital?
governing board
Authentication methods include __________.
handwritten signature rubber stamp signature electronic signature
Deemed status means
hospitals have met or exceeded Conditions of Participation to participate in the Medicare and Medicaid programs.
Which of the following types of records may be protected from discovery by privilege?
incident reports
The process of advising a patient about treatment options is known as:
informed consent
Which of the following discovery methods is directed only toward parties involved in the litigation?
interrogatories
What term best describes the process of protecting citizens living in a civilized society that establishes order, provides parameters for conduct, and defines the rights and obligations of the government and its citizens?
law
Tort law
law that involves the right of an individual, corporation, or other legal entity to recover damages for a loss caused by the defendant (tortfeasor or wrongdoer)
Durable power of attorney
legal instrument that appoints an individual to make decisions in the event of another person's incapacitation
A document that informs a health care provider of a patient's desire regarding various life-sustaining treatment is a:
living will
Sally Paper is responsible for gathering information for completion of birth certificates at Sunny View Hospital. After the application for the birth certificate is completed, she should forward each to the:
local vital statistics office
A jury does not
make determinations of the law
Hillcrest Hospital is writing a retention policy for the health information management (HIM) department. Which index must be retained permanently?
master patient index
Sally Jones presents to the department (ED) with lower-left abdominal pain. The ED physician asks the ED clerk to determine if the patient was previously seen in the facility. The quickest way for the ED clerk to obtain this information is to reference the:
master patient index
Which of the following govern(s) the operation of a hospital medical staff?
medical staff bylaws
The Joint Commission's requirements for the minimum contents of the medical staff bylaws include all but which of the following?
medical staff infection control committee
Information about an electronic health record, such as the date and time of data creation is __________.
metadata
Which of the following best describes the role that the HIIM professional should play in HIPAA security compliance?
moderate involvement since the rule is very operational
When served with a court order directing the release of health records, an individual
must comply with it
Procedural due process includes which of the following elements?
notice and an opportunity to be heard
If a healthcare facility sustains physical damage caused by a tornado, the disaster recovery mechanism which provides the greatest protection of the data is __________.
off-site data storage
Which is usually the most secure place to store PHI data?
on your facilities central server
Appellate courts draft
opinions
Every report and every page/screen in a manual or computerized patient record must include:
patient name and identification number
Hillcrest Hospital is conducting research on Alzheimer's disease and wishes to obtain information from its state's registry. Which information below would be unavailable from the registry?
patient names
Data that is directly related to patients is known as:
patient-centric data
Dr. James is completing a report for a medical staff committee. He needs to determine the number of patients admitted by Dr. Tops for the month of July with the diagnosis of anemia. The best source for this information would be the:
physician index
A health care professional who oversees the development, implementation, maintenance of, and adherence to the organization's policies that cover the safeguarding of patient health information is called a
privacy officer
Which of the following record formats links all documentation to a specific problem?
problem-oriented
The chief of surgery wants to determine the number of cholecystectomies performed over the last six months using a scope and as open surgeries. This information can be obtained from the:
procedure index
The abbreviation PCS means:
professional coding specialiast
Fred resigned from his position at University Hospital. According to the HIPAA security rule, his access to the electronic health record system should be terminated
promptly upon resignation
The primary reason for completing medical records in a fashion consistent with medical staff policies and procedures is to:
provide continuity of care to patients
An admission clerk must obtain the reason for the admission when processing a hospital inpatient; this is called the:
provisional diagnosis
The diagnosis that documents the condition or disease for which the patient is seeking treatment is the:
provisional diagnosis
AHIMA recommends that documents of health record destruction include all of the following except
reason for destruction
A formal recording of items, names, or actions is known as a:
register
You are looking at your policies, procedures, training program, etc. and comparing them to the HIPAA regulations. You are conducting
risk assessment
Administrative law
rules and regulations set by government agencies
Autonomy
self-government
Josie has taken a position as the director of HIM at Acme Healthcare. The organization consists of a main medical center and multiple physician offices. Many of the physician offices possess photocopies of patients' records from the main medical center. These records are________.
shadow
Hillcrest Hospital and Endwell Hospital are merging. The new HIM director for both hospitals needs to ensure that the two MPIs are accurately merged. Each hospital currently uses manual MPIs, and they will convert to one automated MPI. Which activity below should the director avoid?
shred the manual MPI within four weeks after the conversion
Ms. Smith analyzes patient records for deficiencies and determines that there are entries that have been authenticated using initials. She needs to identify the author of these entries to clarify information. She should reference the ____ to determine the full name of the author of the entries.
signature legend
Sam Smith, a social worker at Sunny Valley Hospital, reviews a patient's record to obtain information needed for a nursing home referral. He needs to determine the marital status, race, and ethnicity of the patient. This information would be part of the ____ data recorded in the record.
socioeconomic
Responsibility for completing a fetal death certificate is determined by _____.
state law
When external reviewers request access to electronic patient records, the IT professionals at Charity Clinic determine that giving the reviewers a user name and password to access all records in the database is the quickest and easiest approach. As the HIIM Director, your response to this would be to
suggest records necessary for audit be placed in a queue
Pre- and postanesthesia evaluations would be found in a(n) ____ record.
surgical care
Standard of care
the degree of care that a reasonably prudent person should exercise under the same or similar circumstances
Medical record is property of
the facility that created it
A group practice usually consists of:
three or more physicians
A subcontractor of a business associate may
transmit ePHI on the business associate's behalf if it provides satisfactory assurances that the information will be appropriately safeguarded
The documentation of emergency services provided prior to admission is considered clinical/case information.
true
The focus of health care consumers is on primary and preventative care.
true
Which filing order saves time in processing discharged records?
universal chart order
The Electronic Discovery Reference Model (EDRM) ________.
was developed to assist in the e-discovery process
Emergency consent
where an emergency exist and there has been a protest or refusal by an authorized person, but morbid change in condition occurred
The Uniform Health-Care Decision Act (UHCDA) refers to _____.
Selecting an individual to make healthcare decisions for a competent adult
The uniform Health-Care Decision Act (UHCDA) refers to _____.
Selecting an individual to make healthcare decisions for a competent adult
Which of these PHI communications will NOT require encryption on your part?
Sending e-mail from your Hospital address to another address within your hospital
Tom Smith, a patient at Sunny View Hospital, fell out of his bed during his inpatient admission. An incident report was completed at the time of the fall. Smith is suing the hospital because he feels that the nurses were negligent when caring for him. The following actions were taken by the facility. Determine which of these actions should not have occurred. A. The incident report was filed in the risk management office. B. A note was entered in the patient record stating that an incident report was completed. C. A copy of the incident report was filed in the patient's record. D. Defense attorneys for the health care facility reviewed the incident report to prepare for the case.
B and C
Your transcription system is set to back up your hard drive every five minutes. The back up is on the hard drive of another computer. This computer is located in another room next door to the primary computer - what should be done to improve the back up process
Back up on external hard drive
A valid subpoena duces tecumseeking health records does not have to________.
Be signed by the plaantiff and defendant
Dan Smith has recently moved to a new town. He calls Dr. Jones' office to make an appointment for an annual history and physical. It is the policy of Dr. Jones' office to have all new patients request information from their previous health care providers and forward copies to the office prior to their first visit. Dr. Jones reviews Dan's medical information, which includes treatment for alcohol abuse, depression, and documentation of therapy and treatment. This information would most accurately be referred to as:
Behavioral health information
The local police department has contacted the HIM Department of the community hospital, requesting information about a former patient who has been identified as a suspect in a recent felonious assault. Which of the following items about this individual may be disclosed?
Blood type
If two healthcare professionals disagree about the course of treatment for a patient, how should this be documented in the health record?
Both professionals should record their opinions in the record independently of the other.
Internal medicine
Branch of medicine involving the diagnosis and treatment of diseases and conditions of internal organs such as the respiratory system. The physician is an internist.
The latest provisions to HIPAA include___________.
Breach notification, enforcement and modifications to the privacy and security rules
Which of the following is an example of mitigation?
Breach notification;apology;payment of a bill for financial loss resulting from an infraction
In regard to protecting the concept of privileged communication, a healthcare provider who wrongfully releases a patient's record may be accused of __________.
Breach of fiduciary duty
A subpoena duces tecum compels the recipient to
Bring records to a legal proceeding.
Which of the following would provide the best support of an organization's efforts toward compliance with the security rule?
Build security into software and systems
The computer system containing the computerized patient record was located in a room that was flooded. As a result, the system is inoperable. Which of the following would be implemented?
Business continuity processing
Which of the following are synonymous terms for court decisions? 1. Case law2. Common law3. Statutory law4. Judicial law5. Administrative law
Case law, common law, and judicial law
Which of the following describes alphabetic filing systems?
Changed patient names are cross-referenced.
The negligent tort of malfeasance refers to which of the following statements?
Characterized by the performance of a wrongful act that may be unlawful.
The following legal doctrine was widely recognized by the courts until the landmark ruling of Darling v. Charleston Community Memorial Hospital was issued.
Charitable Immunity
Elaine has moved to a new state to assume the director of HIM in a large community hospital. In her previous position, reporting of trauma injuries was required by state law. However, in her new position it is apparent that the hospital is not reporting traumatic injuries. Which of the following is the most appropriate action for Elaine to take?
Check state law to determine if reporting of trauma injuries is required
Data are sent in encrypted form from one computer to another. Which of the following terms describes the data after the encryption algorithm has been applied to it?
Ciphertext
A coworker comes into Mary's office with a raincoat and wet umbrella. There are no windows in the office and no way to determine the weather outside. Later, Mary is asked to testify as to whether or not it was raining when her coworker entered the office. The raincoat and wet umbrella are what type of evidence?
Circumstantial
State attorneys general can bring
Civil actions in federal court for individuals wronged by HIPAA violations
Alternative dispute resolution is an acceptable option to resolving cases via the court system for
Civil cases and criminal cases
Rule 23 of the Federal Rules of Civil Procedure specifically provides for what type of legal action?
Class action
An admissions clerk enters "right lower abdominal pain" as the admission diagnosis on the face sheet. This information is known as:
Clinical Data
Law based upon judicial decision is called __________.
Common Law
Terminal digit filing
Commonly used in health care facilities that assign digit numbers subdivided into 3 parts: primary, secondary, and tertiary digits. AKA Reverse numeric filing
A patient is admitted for congestive heart failure and hypertension. During the admission, the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a:
Comorbidity
An environmental service employee of the hospital was called to the vascular surgery floor to clean the floor where a bag of potassium chloride had spilled. After cleaning the floor, the employee failed to place any signs advising others of a wet floor. Mrs. Jones, a hospital visitor, fell on the wet floor and injured her back. She incurred medical expenses of $560 and lost wages in the amount of $1,000. She brought suit and the jury awarded her $1,560, representing reimbursement of the medical expenses and lost wages, plus $10,000 for the jurors' perceived recklessness on the part of the hospital. What is the $10,000 amount considered?
Punitive damages
A nursing home administrator places the following advertisement in a local newspaper: "Seeking a health care professional who has the ability to coordinate a program to ensure superior patient care, monitor and improve patient outcomes, monitor facility compliance with accreditation and regulatory standards, and coordinate preparation for surveys." The job title for this professional would be
Quality Manager
Through the establishment of the National Practitioner Data Bank, the federal government became involved in malpractice issues and what other issue?
Quality of Care
Which credentials does AHIMA sponsor?
RHIT, RHIA
Transcriptionists working in specialized areas are more likely to encounter speech recognition technology in the areas of:
Radiology and pathology
What statement best describes the ethical principle of autonomy?
Recognizing the right of a person to make one's own decision
Cancer registry
Records maintained by many states for the purpose of tracking the incidence (new cases) of cancer
Whether or not a health record tends to make the existence of any fact more or less probable than it would be without the record refers to __________.
Relevance
Natural (birth) parents of a child who has been adopted by adoptive parents _____.
Relinquish the right to inspect their child's health records once their parental rights have been terminated
Select the best response to complete this statement: Natural (birth) parents of a child who has been adopted by adoptive parents _____.
Relinquish the right to inspect their child's health records once their parental rights have been terminated
Telephone callback procedures are used primarily for __________.
Remote employees
Under HIPAA, the following disclosures must be included in a patient accounting of disclosures:
Reporting child abuse, venereal disease, occupational diseases
An employer has contacted the Health Information Management Department and requested health information on one of his employees. Of the options below, what is the best course of action?
Request employee's written authorization for release of information
Service of a summons and complaint________.
Requires adequate notice to the defendant and may occur in person or via mail.
Patient Self-Determination Act
Requires consumers to be provided with informed consent, information about their right to make advance health care decisions (called advanced directives), and information about state laws that impact legal choices in making health care decisions.
The burden of proof falls upon the defendant, contrary to the usual burden of proof requirement, except in cases that apply this principle __________.
Res ipsa loquitur
What is the term used to denote the liability of an employer for the acts of its employees?
Respondeat superior
Mr. Green won a $500,000 lawsuit against Dr. Blue. Dr. Blue has appealed. Upon appeal, Mr. Green is referred to as the________.
Respondent
Which of the following entity authentication processes would be the most difficult to breach?
Retinal scan
What rights does a competent individual have in regard to his or her healthcare?
Right to consent to treatment Right to access his or her own phi Right to refuse treatment
Which committee ensures patient safety by analyzing trends of incidents and establishing priorities for dealing with high-risk areas?
Risk Management
You are walking around the facility to identify any privacy and security issues. You walk onto the 6W nursing unit and are able to watch the nurse entering confidential patient information. You make a note of this. What are you doing?
Risk assessment
Kelly is a nurse at Riverview Hospital. She believes there are numerous HIPAA privacy rule violations occurring, but they are not being corrected even though she has brought them to the privacy officer's attention. She contacts the Office for Civil Rights (OCR) to complain. Riverview Hospital learns that she has submitted a complaint to OCR
Riverview may retaliate neither against Kelly nor against patients who complain of violations
Kelly is a nurse at Riverview Hospital. She believes there are numerous HIPAA privacy rule violations occurring, but they are not being corrected even though she has brought them to the privacy officer's attention. She contacts the Office for Civil Rights (OCR) to complain. Riverview Hospital learns that she has submitted a complaint to OCR.
Riverview may retaliate neither against Kelly nor against patients who complain of violations
Uniform access to patient information for all nursing staff best describes
Role-based access
Uniform access to patient information for all nursing staff best describes __________.
Role-based access
The most common place to find intrusion detection software would be on the network __________.
Routers
Dr. Watson is known to chronically not remember his password and ask other physicians and nurses to use their passwords. This is reported by various staff, but the security officer ignores the complaints since Dr. Watson is the chief of staff. The hospital most likely has not complied with which of the following?
Sanction policy
