Chapters 8-10 Legal

Which is an example of emancipation of a minor?

17-year-old who enters the armed forces

Describe what a certificate of destruction is and how long it should be kept.

A certificate of destruction is a document that shows what data and records were destroyed, who destroyed them, and how they destroyed them. These are permanent.

Which scenario is an example of informed consent?

A pregnant 21-year-old girl gives her permission to undergo cesarean section delivery.

Authorship of a health record entry may be complicated by _____.

Allowing the user to copy and paste, possibly into the wrong record

Release of information of HIV records may be made without patient consent in the event that

An emergency situation exists, requiring patient records

A nurse writes a verbal order from a physician on the physician order sheet in the health record; the nurse is the _____ of the entry.

Author

Specialized patient records are especially characterized as _____.

Being voluminous, creating storage issues

Which is an example of a nonclinical use of the health record?

Billing to and reimbursement by third-party payers.

That part of the health record used for continuity of care is the _____ information.​

Clinical

The legal health record is defined as that containing the

Complete and accurate description of the patient's history, condition, and care provided and created by the healthcare organization

When an incorrect entry is documented in the electronic health record (EHR), the responsible provider documents the correction as an addendum in a new document and a(n) _____ links the original document (that contains the incorrect entry) to the addendum.

Computer code

Which of the below is part of informed consent?

Consent must be received from a competent adult for it to be valid

Discovery requests for information from a patient records must be complied with when _____.

Court orders authorizing disclosure are based on a finding of good cause

If a patient requests that his health record be corrected or altered, the provider may proceed by reviewing the information and _____.​

Denying the patient's request and informing the patient of this in writing

Federal and state statutes (laws) that directly impact the quality of the health record include requirements about _____.​

Documentation requirements

The official record regarding mental health care is _____.

Documented by providers and includes care and treatment

The focus of the passage of the Patient Self-Determination Act (PSDA) is to _____.

Ensure that a patient's right to make health-care decisions is communicated and protected

Mental health records can be released just like a general medical record.

False

The Freedom of Information Act applies to _____.

Governmental record-keeping only

After the destruction of records, a certificate of destruction ____.

Indicates what was destroyed as well as the method of destruction

The use of physician handwritten signature stamps to authenticate health record entries _____.​

Is no longer acceptable by CMS as a means of authentication

The confidentiality of HIV information _____.

Means a positive test result can be disclosed without prior consent to protect the public if actions are taken to protect the patient's identity

The proper disclosure of home health care records is regulated by _____.

Medicare conditions of participation

Privacy refers to the right to be left alone. Confidentiality is the _____.

Obligation of a healthcare provider to prevent dissemination of patient information

Records held by a state agency correspond with principles of FOIA and fall into the _____ category of confidentiality protection.

Open record

Which legislation was enacted to allow patients to create advance directives while competent?

PSDA

If the patient does not sign an authorization to release information to the _____, the disclosure of mental health records is prohibited.

Patient's employer

Which of the following is a difference between confidentiality and privacy?

Privacy is the right that patients have to be left alone and to control access to their health information.

When evaluating informed consent, expert testimony regarding disclosure of information to the patient is based on the _____ standard.

Professional disclosure

HIPAA addresses genetic testing by _____.

Prohibiting it from being considered a preexisting condition for health insurance

The Genetic Information Non-Discrimination Act (GINA) _____.

Prohibits third-party payers from raising health insurance rates on a group or individual identified by genetic testing

A substance abuse treatment release of information is invalid if it fails to include the _____.

Purpose of disclosure

Substance abuse health information is _____.

Released via specific authorization

release of mental health information is _____.

Subject to strict rules regarding confidentiality, pursuant to individual state laws

Which is an example of medical information associated with the health record?

Test results and operative reports

Describe the best way to make a correction to a paper based record.

To draw a single line through the entry and write error next to it with the current date, time, and initials of person making the correction.

Advance directives are written instructions recognized under state law, such as living wills or durable power of attorney for health care, that relate to the kind of health care the patient wishes to have or not have when incapacitated.

True

Confidentiality is the obligation of the health care provider to maintain patient information in a manner that will not permit dissemination beyond the health care provider.

True

HIV/ AIDS confidentiality statutes place restrictions on identifying both the patient tested and the test result.

True

J.C. and AOA are accrediting bodies.

True

Name, address information, date, phone number, etc. are all considered individual identifiers under HIPAA.

True

The right to privacy is not specifically mentioned in the U.S. Constitution, but the U.S. Supreme Court has determined that a fundamental right to privacy exists. However, the patient's interests versus the public's right to know must be balanced and sometimes the courts will find that although a patient has a right to privacy, that right is overridden by the public's right to know, such as in the _____ court case.

Whalen v. Roe

​State laws may provide additional requirements regarding mental health care documentation in excess of federal regulations, such as _____.

Written program plans with goals of treatment

Which is considered an identifier of protected health information?

admission date

State laws regarding substance abuse records _____.

may be equal to, less restrictive than, or more restrictive than federal law

A specialized patient record contains diagnoses regarding _____.

mental illness

The phrase deeming authority means to substitute CMS compliance with _____.​

standards of an accrediting organization such as TJC are accepted to meet Medicare CoP requirements

Record retention policies address _____.

the length of time a record is maintained

What are two main differences between mental health records and general health records?

​ Additional requirements for patient record content and more stringent privacy requirements are associated with mental health records

When an error is made in the healthcare record, _____.​

​ An addendum to the EHR or paper-based record should be documented, leaving the original entry in place

Which are subject to federal regulations regarding drug and alcohol treatment programs?

​ General hospitals that operate a substance abuse unit that diagnoses and treats patients

The Privacy Act of 1974 _____.

​ Presumes that personal information maintained by the government be kept confidential

Which is an example of acceptable authentication of a medical record entry? ​

​ Specialist who authenticates his own dictated report electronically using a password

Which is an example of financial information associated with the health record?

​ Third-party payer information