Documentation & Confidentiality

Which of the following is a mnemonic you can use to record the changes in patient status? SOSP APPLE APIE None of the above

APIE

If a person may have come in contact with a patient with an infectous disease such as TB, a healthcare worker should ____. Alert that person that they may have become infected with that disease Alert the local health department Contact a HIPAA lawyer Ignore it

Alert the local health department

Confidentiality applies to healthcare workers in _____. Hospitals Outpatient facilities Nurses stations All of the above

All of the Above

HIPAA applies to ______. Hospitals Pharmacies Waiting rooms All of the above

All of the above

Patient medical records are important because they provide ______. A complete and accurate account of a patient's health status A way for an entire team to evaluate a patient's condition The ability for different disciplines to coordinate patient care All of the above

All of the above

In what year did Dr. Lawrence Reed introduce the concept of computerized medical records? 1955 1960 1975 1980

1960

HIPAA laws went into effect in ______.

2002

The Electronic Medical Records Mandate states that public and private healthcare providers must adopt and demonstrate "meaningful use" of electronic medical records by ____________. 2014 2015 2016 2020

2014

HITECH has updated some of the HIPAA guidelines to strengthen civil and criminal enforcement of its rules, and now has ____ categories of violations, and ____corresponding tiers of penalties. 3; 2 3: 3 4; 4 4; 6

4;4

Since the enactment of HITECH, over _________ jobs have been created to implement the Informatics project, with estimates 20% higher by 2018. 50,000 100,000 150,000 200,000

50,000

Which of the following situations would result in a "handoff" of patient care from one professional to another? A nurse goes on a regularly scheduled break A nurse takes a lunch break A change of shift occurs All of the above

A change of shift occurs

The American Nurses Association established standards which include a patient's right to _________. Privacy with respect to his or her individually identifiable health information Access and review of his or her own health information Receive easily understood notification as to how his or her health records will be used All of the above

All of the above

Which of the following is a benefit of electronic documentation? Documentation can be done at the patient bedside in real time All entries are legible, and not subject to interpretation Data is available to everyone who needs it All of the above

All of the above

Which of the following will help ensure computer-related patient privacy? Having all computers password protected Monitoring all data searches Logging off when you have finished your entries All of the above

All of the above

What entity would be likely to use information in a patient medical record to code specific reimbursements? An insurance company A physician's office A laboratory A legal firm

An insurance company

HITECH has changed HIPAA regulations to stipulate that violations that proceed to court involving less than 500 people are now cases brought by the _____________. Individuals involved Local prosecutors Attorneys General Department of Health and Human Services

Attorneys General

It is against federal law to reveal the identity of a patient attending ____. A drug or alcohol rehab program A psychiatric facility Both a drug or alcohol rehab program or a psychiatric facility A rehab program, except to merely confirm that that person is attending

Both a drug or alcohol rehab program or a psychiatric facility

White Boards __________. Can no longer be visible to the public Are not covered by HIPAA Can no longer be used Must be located in a nurses station

Can no longer be visible to the public

A form of documentation that generates entries into a patient record only when a standard of practice is not met is called _____________. Case management charting Focus charting Charting by exception Objective charting

Charting by exception

When you are writing on a paper chart and make a mistake, you should ___________. Use an eraser to eliminate the incorrect entry Use correction fluid to eliminate the incorrect entry Draw a line through the incorrect entry Mark an "X" through the incorrect entry

Draw a line through the incorrect entry

If a patient receives any treatment, such as administration of pain medication, a nurse should document both the treatment and the treatment's ______________. Effectiveness Suitability for the patient Cure rate Potential side effects

Effectiveness

The __________ Rule sets the penalties for violating HIPAA regulations. Enforcement Privacy Penalty Security

Enforcement

To maintain patient privacy, a hospital may release medical information about a patient as long as the patient's name is withheld.

False

A form of documentation that is organized into columns that may be labeled D-A-E is called _____________. Case management charting Focus charting Charting by exception Objective charting

Focus Charting

What went into effect in 2001 to ensure that an individual's health information is properly protected and that privacy is always maintained? HITECH HIPAA Institute of Medicine Joint Commission

HIPAA

Which of the following was part of the federal government's American Recovery and Reinvestment Act of 2009? HITECH HIPAA Institute of Medicine Joint Commission

HITECH

In the healthcare industry conversion from paper patient records to computer-based medical records has created a new academic field of study called __________. Medi-IT Informatics CompuMed None of the above

Informatics

In 1991, what entity published a report that detailed a vision for the creation of electronic medical records in the United States? The Joint Commission HIPAA Institute of Medicine HITECH

Institute of Medicine

In which case would it be permissible for coworker to pull up a patient record using your password and ID? If they are in a rush If they treat the same patient If they are very quick about it It is never permissible

It is never permissible

The American College of Healthcare Executives recommends: Limiting the use of PHI as much as possible That the use or disclosure of PHI in absence of a patient's signed informed consent document be prohibited unless there is a threat to the public or a compelling law enforcement need That safeguards for the use, disclosure, and storage of PHI be developed Limiting PHI access to authorized personnel only

Limiting PHI access to authorized personnel only

For patients who have HIV, ______. Many states require you to reveal this information to anyone who asks Many states treat this information as public knowledge Many states have laws that make revealing this a criminal offense You may only tell other healthcare workers who may be at risk

Many states have laws that make revealing this a criminal offense

The obligation to maintain confidentiality applies to ______. Medical information only Personal information only Even the presence of the person in the ward Medical and personal information

Medical and personal information

Because verbal and telephone physician orders are very susceptible to error, the Joint Commission developed the ___________ to help alleviate errors. Standard Precautions System Medication Management Standard National Patient Safety Goals None of the above

Medication Management Standard

Because a patient medical record is a legal record of patient care and may be subpoenaed for litigation purposes, you should always __________________. Avoid making entries that you must sign Freely admit your errors and mistakes Never use personal or interpretive descriptions of patient behavior Omit entries that are unflattering to the facility

Never use personal or interpretive descriptions of patient behavior

In waiting rooms, the use of sign-in sheets and publicly calling out patient names are both allowable as long as: Patients sign a release form 100% accuracy is maintained No other information is disclosed None of the above

No other information is disclosed

Physicians can publicly share a patient's _____ if the patient's name is not disclosed. Health Status Medical Record Number Photographs None of the above

None of the Above

Documentation based on what you see, hear, observe and smell is known as _____________. Subjective documentation Objective documentation Deductive documentation Reactive documentation

Objective Documentation

In general, information about a patient can be shared ______. When it is directly related to treatment Only when it is not related to treatment Only when the a patient authorizes it specifically Only with other medical personnel

Only when the a patient authorizes it specifically

The Health Insurance Portability and Accountability Act (HIPAA) requires that you protect patient confidentiality in which forms?

Oral, Written, & Electronic

In some states disclosure of ______ about a minor may be a breach of the law. Pregnancy or rape Any information All medical information Personal information

Pregnancy or Rape

Unlicensed individuals who can enter information into the electronic medical record are known as ______________. Medical assistants Stenographers Scribes None of the above

Scribes

All of the following are examples of exceptions to the Privacy Rule EXCEPT: Cases of child, elder, or domestic abuse or violence Adverse reactions to drugs or medical devices Sending data to a payer Emergency or life-saving interventions for an unstable patient

Sending data to a payer

An exception to confidentiality requirements may exist if you observe ______. Signs of abuse General belligerence Signs of AIDS Signs of TB

Signs of Abuse

The practice of writing about patient encounters and responses on a separate form other than directly into the patient medical record is known as ____________________. Objective oriented documentation Source oriented documentation Subjective oriented documentation Problem oriented documentation

Source oriented

If a caller phones the hospital unit asking for PHI and has not been given permission to receive it or does not know the password _____. PHI can be shared, if they are a spouse Staff should politely explain that patient privacy laws prevent them from giving out any information PHI can be shared, if they are an attorney Staff should ask the caller the appropriate password recovery question

Staff should politely explain that patient privacy laws prevent them from giving out any information

Documentation based upon what a patient tells you about how he or she is feeling is known as _________. Subjective documentation Objective documentation Deductive documentation Reactive documentation

Subjective Documentation

The following is NOT an exception to HIPAA: Instances of child abuse The patient is a public figure Instances of domestic violence Instances of criminal behavior

The Patient is a public figure

Which of the following is NOT an Administrative Simplification rule? Transaction and Code Sets Rule Confidentiality Rule Enforcement Rule Privacy Rule

Transaction and Code Sets Rule

After every chart entry you make, you should sign the notation with your first initial and last name, including your credentials. True False

True

Facilities are charged with not only training staff about HIPAA regulations but also altering the physical layout of nurses stations, office reception areas, or waiting rooms to assure protected patient information is not accidently seen or overheard.

True

HIPAA requires that you limit the disclosure of any patient information to the minimum necessary for the immediate purpose and that you prevent any hospital visitors or others from having casual access to this information.

True

Healthcare providers can share patient information, medical tests, reports and other medical data with one another without needing specific patient authorization as long as it is for treatment purposes, or to complete material for a third-party payer.

True

In accordance with HIPAA, terminal screens are always positioned out of public view.

True

Nurses should make documentation entries both at the start of every shift and when a patient's care is transferred to them from another department. True False

True

One of the benefits of electronic, or computer-based, documentation is that it allows you to utilize a problem-solving approach to patient care.

True

Pharmacists may use their professional judgment in releasing a prescription to a person other than the patient.

True

Protected health information is any information about a person's health, in any form—written, spoken or electronic—that includes the patient's name or other individual identifiers, such as a birth date or medical record number.

True

According to HIPAA regulations, patient information may be released _____________. When patient injuries are associated with criminal activities When the patient tests positive for a sexually transmitted disease When a patient is verbally abusive to medical staff When cause of death is certified by a coroner

When patient injuries are associated with criminal activities

The general privacy rule states that patients have to be notified of the institution's privacy policies, and you must make a good faith effort to obtain ________________. Verbal consent Complete compliance Written acknowledgement None of the above

Written Acknowlegement