RHIT Exam Ch. 12
A health care organization's compliance plans should not only focus on regulatory compliance, but also have a A. coding compliance program that prevents fraudulent coding and billing. B. component that increases the security of medical records. C. substantial program that increases the availability of clinical data. D. strong personnel component that reduces the rapid turnover of nursing personnel.
A
Dr. Sam Vineyard improperly performed a knee replacement surgery, which caused the patient to develop an infection that lead to the amputation of the leg and thigh. The best term to describe the action performed is A. misfeasance. B. malfeasance. C. malpractice. D. nonfeasance.
A
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets forth all of the following EXCEPT A. covered entities provide every patient with its annual business report. B. covered entities' obligations for protecting the patient's PHI. C. patient's rights regarding the covered entities' uses and disclosures. D. how covered entities may use and disclose PHI.
A
If the patient record is involved in litigation and the physician requests to make a change to that record, what should the HIM professional do? A. Refer request to legal counsel. B. Say the record is unavailable. C. Notify the patient. D. Allow the change to occur.
A
In electronic health records, authentication may be achieved by A. digital signature. B. digital signature, handwritten signature, and verbal statement. C. handwritten signature. D. verbal statement.
A
What source or document is considered the "supreme law of the land"? A. Constitution of the United States B. Supreme Court decisions C. Bill of Rights D. presidential power
A
Substance abuse records cannot be redisclosed by a receiving facility to another health care facility unless the A. patient gives written consent. B. physician signs the DNR form. C. patient expires at the receiving facility. D. charge nurse signs the release form.
A
The Darling v. Charleston Community Memorial Hospital case established the following doctrine for hospitals to observe and changed the way hospitals dealt with liability. A. doctrine of corporate negligence B. doctrine of respondeat superior C. doctrine of res ipsa loquitur D. doctrine of continuing wrong
A
The fee paid for reimbursement for expenses incurred from providing health information whether for subpoena or reproduction by health care providers is determined by the A. statute or court rules. B. plaintiff and defendant lawyers. C. hospitals and lawyers. D. American Health Information Management Association.
A
Which type of law is constituted by rules and principles determined by legislative bodies? A. statutory law B. administrative law C. case law D. common law
A
The body of law founded on custom, natural justice and reason, and sanctioned by usage and judicial decision is known as A. statutory law. B. common law. C. constitutional law. D. lien law.
B
A 73-year-old male was admitted to the Sunset Nursing Facility with senility, cataracts, and S/P cerebrovascular accident with right-side hemiplegia. On his second day at the facility, the resident was discovered to have extensive thermal burns on his buttocks and legs by one of the facility's attendants. Referring to Case Study #3, the resident's family brought . legal action against the nursing facility for A.assault and battery. B. negligence. C. medical abandonment. D. vicarious liability.
B
A record that has been requested by subpoena duces tecum is currently located at an off-site microfilm company. By contacting the microfilm provider, you learn that the microfilm is ready and the original copy of the record still exists. What legal requirement would compel you to produce the original record for the court? A. motion to quash B. best evidence rule C. hearsay rule D. subpoena instanter
B
According to AHIMA and AHA guidelines, which of the following would be an acceptable authorization for release of information from the medical record of an adult, mentally competent patient hospitalized from 4/16/2011 to 5/10/2011? An authorization dated A. 5/09/2013 and presented 1/15/2014 B. 7/10/2013 and presented 7/15/2013 C. 3/10/2013 and presented 5/15/2013 D. 2/15/2013 and presented 1/10/2013
B
According to AHIMA's Position on Transmission of Health Information, the health information manager should engage in all of the following to ensure that information is properly sent via facsimile transmission EXCEPT A. ask the sender to contact the recipient prior to and after transmission. B. to always follow up by sending the original record by mail. C. to preprogram into the machine the number of destination sites. D. encrypt the data if public channels are used for electronic transmittal.
B
Consent forms may be challenged on all the following grounds EXCEPT A. the signature was not voluntary. B. the treating physician obtained the patient's signature. C. it is written in a language that the patient could not understand. D. wording was too technical.
B
Laws that limit the period during which legal action may be brought against another party are known as A. common law. B. statutes of limitations. C. summons. D. case law.
B
Mandatory reporting requirements for vital statistics generally A. do not apply to health care facilities. B. do not require authorization by the patient. C. require authorization by the physician. D. require authorization by the payer.
B
Medical record information may be exempt from the Freedom of Information Act requirements if the request for information meets the test of being an unwarranted invasion of personal privacy. Which of the following is NOT one of the conditions of the test? A. Disclosure of the information constitutes an invasion of personal privacy. B. The information is generated from federally funded research conducted by a private health care organization. C. The severity of the invasion must outweigh the public's interest in disclosure. D. The information must be contained in a personal, medical, or similar file.
B
Which of the following is an example of the breach of confidentiality? A. the hospital operator paging code blue in room 3 north B. staff members discussing patients in the elevator C. the admission clerk verifying over the phone that the patient is in-house D. a nurse speaking with the physician in the patient's room
B
You are the Director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions. Referring to Case Study #2, what phase of the lawsuit are you involved in? A. pretrial conference B. discovery C. trial D. appeal
B
A written authorization from the patient releasing copies of his or her medical records is required by all of the following EXCEPT A. a physician requesting copies from another physician. B. an insurance company. C. the hospital attorney for the facility where the patient is treated. D. the patient's attorney.
C
A 73-year-old male was admitted to the Sunset Nursing Facility with senility, cataracts, and S/P cerebrovascular accident with right-side hemiplegia. On his second day at the facility, the resident was discovered to have extensive thermal burns on his buttocks and legs by one of the facility's attendants. Referring to Case Study #3, which of the following can the attorney of the resident's family also use as a basis for the lawsuit and why? A. The doctrine of charitable immunity because the nursing facility is a private institution and is shielded from liability for any torts committed on its property. B. The Good Samaritan Statutes because they protect the Director of Nursing, an employee of the nursing facility, who was not present when the injury occurred. C. The doctrine of res ipsa loquitur because it allows the plaintiff to shift the burden of proof to the defendant because direct evidence is available. D. The failure to warn theory because the doctor did not inform the resident's family that the resident was in danger at the nursing facility.
C
In a negligence or malpractice case, all of the following elements must be present in order to shift the burden of proof onto the defendant EXCEPT the A. plaintiff did not contribute to the injury. B. event would not normally have occurred in the absence of negligence. C. health care facility does not have a risk management program. D. defendant had exclusive control over the instrumentality that caused the injury.
C
The extent to which the HIPAA privacy rule may regulate an individual's rights of access is not meant to preempt other existing federal laws and regulations. This means that if an individual's rights of access A. are greater under another existing federal law, HIPAA can obstruct freedoms of the other federal law when using electronic health records. B. are refused by a federal facility, HIPAA must also refuse the individual of the access. C. are greater under another applicable federal law, the individual should be afforded the greater access. D. are less under another existing federal law, HIPAA must follow the directions of that law.
C
Under traditional rules of evidence, a medical/health record is considered ______________ and is ___________________ into evidence. A. reliable; inadmissible B. reliable; admissible C. hearsay; inadmissible D. hearsay; admissible
C
Who decides whether all or portions of the medical record will be received in evidence in a court of law? A. subpoenaing attorney B. clerk of the court C. presiding judge/court D. defendant
C
A written consent from the patient is required from which of the following entities in order to learn a patient's HIV status? A. spouse or needle partner B. emergency medical personnel C. health care workers D. insurance companies
D
All of the following need a proper authorization to access a patient's health information EXCEPT A. IRS agents. B. local and state law enforcement officers. C. FBI agents. D. medical examiners or coroners.
D
An improper disclosure of patient information to unauthorized individuals, agencies, or news media may be considered a(n) A. slander. B. libel. C. defamation. D. invasion of privacy.
D
Dr. Vincent Orangeburg performed a cesarean on Mrs. Greentree, who later returned to the emergency room 5 days after the surgery with abdominal pain. An x-ray performed revealed that a sponge was left in the lower abdominal cavity from the cesarean. Which case law principle can be used in a lawsuit against Dr. Orangeburg? A. star decis B. res judicata C. res gestae D. res ipsa loquitur
D
In a court of law, Attorney A, the attorney for Sun City Hospital, introduces the medical record from the hospital as evidence. However, Attorney B, the attorney for the defendant, objects on the grounds that the medical record is subject to the hearsay rule, which prohibits its admission as evidence. Attorney B's objection is overridden. Why? A. It would violate physician-patient privilege, even though the patient signed a proper release of information form. B. The doctrine of res ipsa loquitur prevails; therefore, reference to the medical record is moot. C. The medical record does not belong to the hospital; therefore, the hospital has no right to release the medical record as evidence. D. The medical record may be admitted as business records or as an explicit exception to hearsay rule.
D
In general, which of the following statements is correct? A. When federal and state laws conflict, valid corporate policies supersede federal and state laws. B. When federal and state laws conflict, valid state laws supersede federal laws. C. When federal and state laws conflict, valid local laws supersede federal and state laws. D. When federal and state laws conflict, valid federal laws supersede state laws.
D
In which type of facility does the Privacy Act of 1974 permit patients to request amendments to their medical record? A. university-based teaching facility B. mental health and chemical dependency facility C. private proprietary health care facility D. Department of Defense health care facility
D
Spoliation is the term that refers to the wrongful destruction of evidence or the failure to preserve property, which addresses which of the following methods of discovery? A. deposition B. request for admissions C. interrogatories D. e-discovery
D
The failure to obtain the written consent of the patient before performing a surgical procedure may constitute A. libel. B. contempt. C. malpractice. D. battery.
D
The ownership of the information contained in the physical medical/health record is considered to belong to the A. physician. B. insurance company. C. hospital. D. patient.
D
The protection of a patient's health information is addressed in each of the following EXCEPT A. Drug Abuse and Treatment Act. B. Health Insurance Portability and Accountability Act. C. Privacy Act. D. U.S. Patriot Act.
D
To be admitted into court as evidence, medical records or health information are introduced as A. torts or contracts. B. privileged information. C. product liability. D. business records or exception to hearsay rule.
D
Which of the following claims of negligence fits into the category of res ipsa loquitur? A. improper use of x-rays B. incorrect administration of anesthesia C. failure to refer patient to a specialist D. leaving a foreign body inside a patient
D
Which of the following elements of negligence must be present in order to recover damages? A. duty of care; breach of duty of care; value attached to injury is greater than a certain value (ordinarily $1,000); provisions of the HIPAA privacy rule have been met B. duty of care; breach of the duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000) C. breach of duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000); provision of HIPAA privacy rule have been met D. duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm
D
While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation? A. Remove the incident report and send it to the patient. B. Tell the employee to leave the report in the record. C. Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record. D. Refer this record to the Risk Manager for further review and removal of the incident report.
D