HealthCare Law and Ethics
Court order
(1) An adjudication by a court. (2) The ruling by a court with respect to a motion or any other question before it for determination during the course of a proceeding.
Which is an example of emancipation of a minor?
17-year-old who enters the armed forces
Which constitutional amendment prohibits double jeopardy?
5th
Quid pro quo
A Latin phrase meaning "this for that"; a type of sexual harassment
Probable cause
A belief based on specific facts that a crime has been or is about to be committed.
Law
A body of rules of action or conduct prescribed by a controlling authority that has binding legal force.
Exempt employee
A category under the Fair Labor Standards Act for an employee who is paid a salary as opposed to wages, exercises discretion in performing his work, is primarily responsible for managing a business or department, routinely manages others, and possesses the authority to hire and fire other employees.
Causation
A causing; the producing of a result.
Personal health record
A collection of a patient's important health information that can be drawn from multiple sources and that is managed, shared, and con- trolled by or primarily for the individual patient.
Subpoena
A command in the form of written process requiring a witness to come to court to testify; short for subpoena ad testificandum.
Privilege
A concept protecting the statements made by persons within a specific relationship, such as attorney- client, from forced disclosure.
Consent
A concurrence of wills. An agreement by a person in the possession and exercise of sufficient mental capacity to make an intelligent choice to do something proposed by another.
Health care relationships
A connection between a health-care provider, patient, and/or hospital that serves as the basis of a lawsuit.
Hospital-physician relationship
A contractual agreement between the physician and the hospital allowing the physician to bring patients to the hospital to receive treatment.
Show cause order
A court decree directing a person or organization to appear in court and explain why the court should not take a proposed action. If the person or organization fails to appear or sufficiently persuade the court to take no action, the court will take the action originally proposed.
Warrant
A court's prior permission for the police to search and seize.
Mandatory testing
A decision by the legislature or court that forces an individual to receive testing for some health reason, without granting the individual the right to refuse.
Charitable immunity
A defense that shields a charitable institution from liability for any torts committed on its property or by its employees.
Permissive and mandatory exclusion
A deterrent to fraud and abuse where the health-care provider is barred from participation in the Medicare program and all other federally financed health-care programs.
Physical examination
A discovery device used to evaluate the physical condition of a plaintiff in a lawsuit when such condition is in question.
Electronically stored information (ESI)
A distinct category of information that includes e-mails, Web pages, word processing files, and databases stored in the memory of computers, magnetic discs (such as computer hard drives and floppy disk), optical discs (such as DVDs and CDs), and flash memory (such as thumb or flash drives).
Preemption
A doctrine adopted by the U.S. Supreme Court that certain matters are of such a national, as opposed to local, character that federal laws preempt or take precedence over state laws. As such, a state law inconsistent with that of the federal law will be held invalid.
Corporate negligence
A doctrine defined as the failure of a hospital, entrusted with the task of providing the accommodations necessary to carry out its purpose, to follow the established standard of conduct to which it should conform.
Assumption of risk
A doctrine stating that a plaintiff who voluntarily exposes himself or herself to a known and appreciated danger may not recover damages caused by incurring that risk.
Vicarious liability
A doctrine that makes a health-care organization responsible for the negligent acts of its employees committed within the course and scope of their employment. Also known as respondeat superior.
Governmental immunity
A doctrine that precludes a plaintiff from asserting a meritorious lawsuit against a governmental entity unless the governmental entity consents to the lawsuit.
Health record
A document that contains a complete and accurate description of a patient's history, condition, diagnostic and therapeutic treatment, and the results of treatment.
Record retention schedule
A document that details what data will be retained, the retention period, and the manner in which the data will be stored.
Certificate of destruction
A document that shows what data and records were destroyed, who destroyed those data and records, and the method used for that destruction.
Belmont Report
A document which identifies the ethical principles to be used to prevent unethical use of human subjects in research.
Living will
A document, executed while a patient is competent, that provides direction as to medical care in the event the patient is incapacitated or unable to make personal decisions. A form of advance directive; each state must determine the legal rights of the patient to use a living will.
Fraud and abuse
A false misrepresentation of fact that is relied on by another to that person's detriment and is a departure from reasonable use. This false misrepresentation of fact may take the form of words or conduct.
Reasonable fee
A fee charged by the health-care provider for the reproduction of the medical record. Individual facilities have policies determining what a reasonable fee should be. The amount of the fee is a controversial national issue.
Civil money penalty
A fine imposed on a health-care provider who files false or fraudulent claims.
Limited data set
A form of data in which direct identifiers have been removed.
E-discovery
A form of discovery that focuses on information stored electronically, such as that contained in electronic health records, and requires collecting, preparing, reviewing, and producing electronic documents in a variety of criminal and civil actions and proceedings.
Hostile work environment
A form of sexual harassment involving unwelcome sexual conduct that is sufficiently pervasive or severe enough to alter the terms or conditions of employment.
Encryption
A form of technical security used to ensure that data transferred from one network location to another is secure from eavesdropping or interception.
Institutional review board (IRB)
A group formally designated by an institution to safeguard the rights and welfare of human subjects by reviewing, approving, and monitoring medical research.
Anti-kickback statute
A law prohibiting the offer or solicitation of remuneration, including kickbacks and rebates, in exchange for referrals of Medicare-payable services.
Accounting of Disclosures
A list of all disclosures made of a patient's health information.
Corrections to the record
A method by which a mistake contained in a patient's health record is altered or modified according to standard practices.
Failure to warn
A negligence theory that applies to a psychotherapist's failure to take steps to protect an innocent third party from a dangerous patient. Also known as failure to protect.
Notice of privacy practices
A notice required by law that requires the health-care provider to notify the patient of the uses of patient-specific health information and provide an opportunity to consent, reject, or request restriction of the information for any of the uses contained in the notice.
Incompetent
A person who is unable or unfit to make decisions.
Disability
A physical or mental impairment that substantially limits one or more of the major life activities of an employee; a record of such impairment; or being regarded as having such an impairment.
Functional limitation
A physical or mental limitation of a major life activity caused by a disability.
Plain view doctrine
A policy that allows police to seize contraband or evidence that is openly visible in an area where the police are authorized to be.
Categorical imperative
A principle of deontology that means a command derived from a principle that does not allow exceptions.
Unemployment insurance
A program designed to provide regular income to those who have lost their jobs.
Workers' compensation
A program designed to replace income and provide medical expenses to employees who are injured, become ill, or die as a result of their jobs.
Compliance Program
A program ensuring the use of effective internal controls that promote adherence to the applicable local, state, and federal laws and regulations and the program requirements of federal, state, and private health plans.
Salary
A rate of pay given on a weekly, monthly, or yearly schedule.
Official record
A record containing that information necessary to document the patient's care and treatment: history and mental status exam, consent forms, treatment plans, physician orders, laboratory results, etc. This record is required to be maintained by law.
Personal record
A record, separate from the official medical record, maintained by the clinician in the mental health or developmental disability context that gives the clinician's viewpoint of the patient and their communications.
First step to establishing liability is that _____.
A relationship must be established between a healthcare provider and a patient
Undue hardship
A specific accommodation that creates significant difficulty or expense for the employer.
Professional disclosure standard
A standard used in the negligence context to determine liability. It is measured according to the level of information a reasonable health-care provider would disclose under the same or similar circumstances.
Reasonable patient standard
A standard used in the negligence context to determine liability. It is measured as the level of care that would be exercised by a reasonably prudent person under the same or similar circumstances.
Which statement is associated with federal regulations regarding the patient identification in a substance abuse program?
A substance abuse treatment facility has an unconditional obligation not to identify patients who have been treated
Anonymous testing
A system that assigns a unique identifier to the individual tested, thereby protecting his or her identity.
Litigation response plan
A tool consisting of policies and procedures that address how to respond to legal process requests.
Electronic signature
A type of signature that uses soft- ware applications to bind a signature or other distinguishable mark to a specific electronic document.
No-knock warrant
A warrant that allows the police to enter without announcing their presence in advance.
Public health threats
A wide variety of health-care problems that potentially endanger the public health and must be reported to a public health agency. Common public health threats include communicable diseases, child abuse, fetal deaths, and cancer.
Tort
A wrong involving a breach of duty and resulting in an injury to the person or property of another. A tort is distinguished from a breach of contract in that a tort is a violation of a duty established by law, whereas a breach of contract results from a failure to meet an obligation created by the agreement of the parties. Examples of activities considered a tort include medical malpractice, defamation, and invasion of privacy.
Punitive damages may be awarded _____.
Above and beyond actual damages
Ethical concepts
Abstract ideas or thoughts that deal with ethics.
phrase deeming authority means to substitute compliance with _____.
Accreditation standards for compliance with CMS regulations
emancipated minor is one who is _____
Actively serving in the US armed forces
Subpoena ad testificandum
Ad testificandum means "testify under penalty." A subpoena ad testificandum is a subpoena to testify.
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
Which is required of psychiatric facilities that receive Medicare funds?
Adherence to conditions of participation for documentation
Which is considered an identifier of protected health information?
Admission date
Health information becomes confidential _____.
After it is made available to the healthcare provider
Which is an example of social information associated with the health record?
Alcohol, tobacco, and work history
Cost-benefit analysis
All possible options are considered, the utility or value of each option is determined, and the option that poses the highest total utility is chosen. Net benefits are compared against costs to reach a decision. The option that offers society the best benefits at the least cost or offers businesses the greatest return for the lowest costs is seen as the logical choice.
Authorship of a health record entry may be complicated by _____.
Allowing the user to copy and paste, possibly into the wrong record
Durable power of attorney
Allows a competent individual to name someone else to exercise health-care-related decisions on his or her behalf, in the event the individual becomes incapacitated or unable to make personal decisions. This term is some- times referred to in a shorten fashion as durable power of attorney.
Federal Privacy Act _____.
Allows a patient greater access to records than is provided for by HIPAA
Which would create an ethical concern?
Altering statistics to meet accreditation requirements
Assault
An act of force or threat of force intended to inflict harm upon a person or to put the person in fear that such harm is imminent; an attempt to commit a battery. The perpetrator must have or appear to have the present ability to carry out the act.
Reasonable cause
An act or omission in which a covered entity or business associate knew, or by exercising reasonable diligence would have known, that the act or omission violated an administrative simplification provision, but in which the covered entity or business associate did not act with willful neglect.
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
Motion to quash
An approved method to challenge a subpoena duces tecum in which a court determines whether documents and things must be produced pursuant to the subpoena.
Etiquette
An area of study focusing on how human beings relate to one another under certain circumstances; a social code of customs and rituals.
Compound authorization
An authorization for use or disclosure of patient-specific health information that has been combined with another document.
Release of information may be made without patient consent in the event that _____.
An emergency situation exists, requiring patient records
Full-time employee
An employee who works thirty hours per week or more.
At-will employment
An employment arrangement that allows the employer to terminate the employee at any time and allows the employee to leave the employer at any time.
Article X of the Evidence Rules allows
An exact duplicate copy to serve as evidence in lieu of an original
Business record exception
An exception to the hearsay rule that permits business records to be admitted into evidence even though they are hearsay. Medical records admitted as evidence under this exception must first meet the foundation requirements of the exception.
Wages
An hourly rate of pay.
Under Title VII, an employer may refuse employment to a person due to:
An inability to speak English
Employee
An individual hired by another, such as a business firm, to work for wages or a salary.
Independent contractor
An individual who agrees to perform certain work according to his or her own means, manner, and methods of performance.
National health information infrastructure
An inter- operable electronic exchange of data between health- care providers, government, and third-party payers.
healthcare provider's obligation regarding a business associate's compliance with the HIPAA Privacy Rule includes _____.
An obligation to monitor the business associate's compliance with HIPAA
Duty of care
An obligation, enforced by law, to con- form to a particular standard of care toward another. Failure to conform to this standard will result in liability for any harm sustained by another person.
Paternalism
An outdated principle in which the health- care professional acts in the role of a father to his children, deciding what is best for the patient's welfare without first being required to consult with the patient.
Which of the following must be demonstrated in order to charge invasion of privacy?
An unwarranted exploitation of an individual's personality occurred
Reasonable accommodation
Any change in the work environment or in the manner in which things are customarily done that enables a qualified person with a dis- ability to have equal employment opportunities.
Serious health condition
Any injury, illness, impairment, or physical or mental condition requiring either inpatient care at a hospital, hospice, or residential medical care facility or continuing treatment by a health- care provider.
Workplace barrier
Any workplace obstacle, whether physical or procedural, that prevents an employee from performing the duties of the job, whether those duties are considered essential or marginal.
Which is an ethical challenges related to coding?
Assigning multiple codes to increase DRG payments
DHHS Office of the Inspector General (OIG) is _____
Authorized to conduct civil and criminal investigations of fraud associated with Medicare
Hospital-patient relationship
Begins when the patient is voluntarily admitted to the hospital and agrees to pay for the treatment to be rendered. The relationship ends when the patient leaves the hospital through discharge or against medical advice.
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
U.S. Supreme Court decides which cases to hear:
By a writ of certiorari
55 year-old male who has been laid off from work at a facility has applied for a position with another healthcare facility. Which is a consideration that should be made in the decision to hire him or not to hire him?
Can he physically perform the job for which he is being considered
parent will not be granted access to the health care record of his or her child who has not yet reached the age of majority when the minor child _____.
Can lawfully obtain health care without parental consent
Employees who are considered at-will employees are those who _____
Can leave an employer or be terminated at any time
Admissibility of the health record into evidence is guided by Federal:
Civil Procedure Rules of Evidence
Which is the most common form of health care fraud and abuse?
Claims and billing practices
From a statutory perspective, CFR is an abbreviation for _____.
Code of Federal Regulations
Which recognizes the patient's right to bring a lawsuit for damages or relief against someone who obtains, releases, or uses protected health information (PHI) inappropriately?
Common law basis
legal health record is defined as that containing the _____.
Complete and accurate description of the patient's history, condition, and care provided
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
Intentional infliction of emotional distress
Conduct by the defendant that is so extreme and outrageous that it causes the plaintiff to suffer severe emotional distress.
Authentication
Confirms the content and accuracy of an entry into the medical record by written signature, initials, or computer-generated signature code.
Which of the below is part of informed consent?
Consent must be received from a competent adult for it to be valid
COBRA is the abbreviation for _____.
Consolidated Omnibus Budget Reconciliation Act
What are financial settlements or arrangements that specify rules of conduct to be followed to remedy any fraud and abuse found plus any monitoring and reporting requirements?
Corporate integrity agreements
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
Which federal government official has the power to promulgate rules and regulations?
DHHS Secretary
Slander
Defamation expressed by oral expressions or transitory gestures made to a third party.
Libel
Defamation expressed in print, writing, pictures, or signs and made available to a third party.
primary responsibility for investigating claims of fraud committed against the military's health insurance programs is the responsibility of the _____.
Defense Criminal Investigative Service
Which changed the nature of compliance programs for some institutions from voluntary to mandatory and provided a financial incentive for states to adopt laws similar to federal laws regarding fraud and abuse?
Deficit Reduction Act
Which provides the most accurate sequence in the ethical decision making process?
Define the issue, determine available options, implement the decision
Which is an example of personal information associated with the health record?
Demographic data, such as address
If a patient requests that his health record be corrected or altered, the provider may accomplish this by _____.
Denying the patient's request by informing the patient of this in writing
To determine if the information provided was sufficient to obtain informed consent, the element of _____ is required.
Description of possible complications
Best Interest Standard
Determining what is in the best interest of another who cannot it determine it for herself
Disclosure of information
Disclosure of health information is governed by two principles: (1) medical records remain within the provider's control and safe- keeping and may be removed only in accordance with a court order or subpoena; (2) the health-care provider may not disclose or withhold health information at will.
Blank _________ can be defined as those devices or tools used by one side to obtain facts and information about the case:
Discovery
In the context of ethics, the belittling or criticizing of skills, knowledge or qualifications of another professional is referred to as _____.
Disparagement
fair distribution of benefits and burdens refers to _____.
Distributive justice
Trial courts in the federal system are called _____.
District
Institutional standards of care _____
Do not carry the force of law
Informed consent is a _____.
Document attesting to the patient's agreement to treatment permitted or provided
Federal and state statutes (laws) that directly impact the quality of the health record include requirements about _____.
Documentation requirements
When obtaining informed consent, which information must be part of the process?
Documentation that discussion occurred
official record regarding mental health care is _____.
Documented by providers and includes care and treatment
Subpoena duces tecum
Duces tecum means "bring with you under penalty." A subpoena duces tecum is a written command requiring a witness to come to court to testify and at that time to produce for use as evidence the papers, documents, books, or records listed in the subpoena. It is often used in the context of health information management to command the custodian of the records to produce a particular record at trial or deposition and provide testimony to the authenticity of the record produced.
Which is an obligation to behave in a certain way, such as the expectation by the medical profession that physicians will act or practice medicine in a reasonably prudent manner?
Duty to Care
What is a process in development to combat increased costs associated with the legal discovery of the electronic health record?
ECRM
Anti-dumping law is abbreviated as _____.
EMTALA
Leased employee
Employees who are employed by a service firm and are assigned to work at a business or an organization; sometimes referred to as temporary employees.
Part-time employee
Employees who work less than thirty hours per week.
employer is obligated to verify the _____ of employees who are hired to work
Employment authorization and identity
Incorporating ethics into an employee's performance evaluation _____.
Encourages the employee to treat others with respect
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
Treatment program
Entities whose sole purpose is to provide alcohol or drug abuse diagnosis and treatment.
In the healthcare context, the distributive justice criterion of equity refers to the _____.
Equal distribution of healthcare procedures and services to all in need
ERISA binds an employer to _____.
Establish minimum standards for employee participation in a company retirement plan
Which is the formal study of moral choices that conform to standards of conduct?
Ethics
Morals and values are internalized concepts, whereas ____ are defined or acknowledged through expressed behaviors regarding ideals.
Etiquette and laws
Which government agency's authority extends beyond the jurisdiction of other government programs?
FBI
patient's friend or family may be given access to medical records in the event that the _____.
Family member is the custodial parent of a minor child
release of health records from drug and alcohol abuse programs is governed by _____ regulations.
Federal
Regulations about medical records are enforced by _____.
Federal and state agencies
Statute of limitation
Federal and state laws prescribing the maximum period of time during which various types of civil actions and criminal prosecutions can be brought after the occurrence of the injury or offense.
Statute of limitations
Federal and state laws prescribing the maximum period of time during which various types of civil actions and criminal prosecutions can be brought after the occurrence of the injury or offense.
When determining which entity's federal or state law concerning the control of health information control is preemptive, the health information manager must understand that the _____.
Federal or state law that is more stringent is followed
Patient identification
Federal regulations restrict identification of a patient who is in a facility publicly identified as providing substance abuse treatment. Written consent of the patient or a court order is required for disclosure.
According to the AMA, it is ethical for a physician to hold a financial interest in a health care facility when the physician's _____.
Financial interest is disclosed to those referred for services
Corporate integrity agreements (CIA)
Financial settlements involving written agreements that specify the rules of conduct to be followed to remedy health-care fraud and abuse, plus any monitoring and reporting requirements.
Foundation Requirements
Foundation requirements of the business record exception must be established during testimony by the health information manager. The manager must possess knowledge of the requirements to create and maintain a medical record issued by governmental entities, accrediting agencies, and internal policies and procedures of the health-care provider, along with knowledge of the manner in which data are recorded.
Which is the false misrepresentation of fact that is relied on by another to that person's detriment and a departure from reasonable use?
Fraud and abuse
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
Exigent circumstances
Generally a time sensitive or emergency situation that allows a search to proceed without a warrant.
Whistle-blowers
Generally, a current or former employee of a health-care provider or organization who has learned of fraud and abuse and wishes to expose the activity.
Ethics committees
Groups formed within an organization to establish new and evaluate existing ethics codes and corporate polices and to address ethical issues that arise in the workplace.
Labor union
Groups of employees joined together to protect their jobs, seek improvements in working conditions, and create a formal method to communicate with the employer as a group.
Declaration of Helsinki applies to _____.
Guidelines followed when conducting research involving human subjects
Federal legislation that specifically addresses the release of protected health information is called _____.
HIPAA
Which implements the concept of gatekeeping to contain healthcare costs?
HMO's
Veracity
Habitual truthfulness and honesty; the opposite of the practice of intentionally deceiving or misleading.
use of physician handwritten signature stamps to authenticate health record entries _____.
Has been eliminated by CMS
employer is permitted to terminate an employee who ____
Has been found guilty of a DUI
Disclosure with patient authorization
Health information may be disclosed to third parties on written authorization of the patient. Certain components must be present for the written authorization form to be valid.
Disclosure without patient authorization
Health information may be disclosed to third parties without written patient authorization in limited circumstances, such as medical emergencies, scientific research activities, and audits.
De-identified data
Health information that is stripped of all identifiers.
De-identified health information
Health information that is stripped of all identifiers.
Specialized patient records
Health records of patients undergoing treatment for certain illnesses, such as sub- stance abuse or mental illness, or in nonacute care set- tings, such as the patient's home. These records are subject to different legal requirements from those in an acute care setting.
Hybrid record
Health records that are based partially in paper form and partially in electronic form.
Which concept provides the original basis for maintaining confidentiality between patient and healthcare provider?
Hippocratic oath
Regulations concerning medical records may control _____.
How they are to be maintained
Authorship
Identifies the health-care provider who has made an entry in the patient record, in writing or by dictation, keyboard, or keyless data entry.
When a substance abuse treatment program is acquired by another program, the next course of action is that _____.
If any patients refuse consent to transfer, those records may be destroyed or retained in compliance with the statute of limitations
If an item was not charted in a health record, it is presumed that _____
If it wasn't documented, it wasn't done
Which legislation requires employers to verify the identity of employees prior to hiring them?
Immigration Reform and Control Act
Which statement about the substance abuse treatment is true?
In certain circumstances, parental consent is required to authorize treatment
Contributory negligence
In the law of negligence, a failure by the plaintiff to exercise reasonable care that, in part at least, is the cause of an injury. Contributory negligence defeats a plaintiff's cause of action for negligence in states that have not adopted the doctrine of comparative negligence.
business or organization has the least control over the work product prepared by _____.
Independent contractors
After the destruction of records, a certificate of destruction ____.
Indicates what was destroyed as well as the method of destruction
Protected health information (PHI)
Individually identifiable health information that is transmitted by electronic media, maintained in electronic medium, or transmitted or maintained in any other form or medium.
Genetic information
Information about an individual or family obtained from a genetic test or an individual's DNA sample. Genetic information relates to a person's future, not past, health.
Pretest counseling provided to a patient for HIV testing includes _____
Information about the types of tests, testing methodology employed, and the meaning of test results
invalid release of information contains _____.
Information known to be false
Which is a major concern regarding the destruction of records?
Information that identifies patients must be maintained as confidential
Autonomy is viewed as a freedom unless it _____
Interferes with another's rights
Questions presented to a party used to gather evidence are part of a(n):
Interrogatory
physician-patient privilege applies to information obtained in the context of _____.
Introduction of evidence at trial
In addition to standard documentation requirements, the Joint Commission requires _____ to be documented in mental health records.
Involvement of the family members in treatment programs
Which statement is associated with civil law?
It is an area of law and justice that attempts to settle disputes among individuals
Which of the following is true regarding the physician-patient privilege?
It is designed to prevent forced disclosure of information by the health care provider
How does the law speak to mandatory testing?
It may be enforced through a court order
Substantially equal
Jobs or work performed under similar working conditions and requiring equal skill, effort, and responsibility.
Standards that apply to facilities providing mental health, mental retardation, and developmental disability services are promulgated by the _____.
Joint Commission
Beneficence refers to _____.
Kindness, mercy, and charity
A release of information (ROI) authorization signed and dated by the patient is considered invalid when it _____.
Lacks a specific description of the information requested
Privacy statutes
Laws that generally correspond with the principles found in the federal Privacy Act: a presumption of confidentiality that may be rebutted with evidence of patient authorization to disclose information.
Physician self-referral prohibitions
Laws that prohibit physicians from referring patients to services when the physician possesses a financial interest in or will receive payment in return for the referral.
Qui tam actions
Lawsuits that allow private plaintiffs to sue on behalf of the U.S. government and receive a portion of the recovered funds if successful.
Defamation
Libel or slander; the written or oral publication, false or intentional, of anything that is injurious to the good name or reputation of another person.
minimum necessary standard refers to the healthcare provider's effort to _____.
Limit patient-specific health information released to that which is needed to accomplish the intended purpose only
HIPAA provides for two exceptions in which approval for research does not require full IRB review. They include _____.
Limited data set and de-identified information
consent to release patient information is required when _____.
Litigators are seeking potential clients
destruction of records _____.
May be performed in the regular course of business following a specified retention period
Accrediting standards _____.
May be used in establishing a standard of care during a negligence action
Substance abuse in the workplace _____
May contribute to illegal behavior to support the habit
Prospective payment systems and health maintenance organizations reward healthcare providers monetarily for maintaining lower costs and penalize those providers who do not keep costs within preestablished limits. With regard to ethics, placing such monetary rewards and penalties before health-care providers _____.
May impact both the quantity and quality of patients' health care
Res ipsa loquitur
Means "the thing speaks for itself." Used only when a plaintiff cannot prove negligence with the direct evidence available to him or her.
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
Placebos
Medically inert substances that are used as a control in testing the effectiveness of another medicated substance.
Which program specifically directs the DHHS to enter into agreements with private companies to carry out fraud and abuse protections?
Medicare Integrity Program
proper disclosure of home health care records is regulated by _____.
Medicare conditions of participation
In the healthcare context, the distributive justice criterion, the potential for benefit after an initial investment of limited resources is referred to as _____.
Merit
personal record relative to mental health care _____.
Might not be subject to discovery in a legal proceeding
Malpractice
Misconduct involving a professional who fails to follow a standard of care prevalent for his or her profession that results in harm to another person.
living wage law requires employers to pay _____.
More than the Federal minimum wage
government agency that establishes and oversees collective bargaining procedures is the _____.
NLRB
Hippocratic oath expresses both _____.
Nonmaleficence and beneficence
Psychotherapy notes
Notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or group, joint, or family counseling session.
health information manager must issue and post the healthcare provider's duties concerning PHI, which is called the _____
Notice of Privacy Practice
Which legislation requires an employer to operate a place of employment free from recognized hazards that are likely to cause serious injury or fatality?
OSHA
Privacy refers to the right to be left alone. Confidentiality is the _____.
Obligation of a healthcare provider to prevent dissemination of patient information
Trustworthiness requirements
One of the requirements of the business record exception to the hearsay rule. It must be established through testimony of the health information manager. To assist in establishing trustworthiness, the manager must possess knowledge of internal policies and procedures governing access to the medical record and quality control techniques, such as approved methods to make corrections to and use abbreviations in the record.
Regular employee
One who has a continuing relation- ship with an employer; sometimes referred to as a common law employee.
Statutory employee
One who has been designated by specific laws as subject to the tax-withholding requirements imposed upon employers but who might not otherwise be considered an employee.
Business associate
One who performs or assists in performing a function or activity involving the use or dis- closure of individually identifiable health information on behalf of a health-care provider.
Which statement is associated with a criminal trial?
Only the defendant may appeal a guilty verdict in a criminal case
Records held by a state agency correspond with principles of FOIA and fall into the _____ category of confidentiality protection?
Open record
Living wage law
Ordinances passed by local governments that require employers to pay employees more than the federal minimum wage.
Hearsay
Out of court statements that are offered to prove the truth of the matter asserted.
Which is an ethical healthcare model wherein the healthcare professional acted in the role a "father to his children?"
Paternalism
If the patient does not sign an authorization to release information to the _____, the disclosure of mental health records is prohibited.
Patient's employer
Federal confidentiality requirements are provided to a patient when _____.
Patients are admitted to a substance abuse treatment program
Patient notice
Patients must be given notice of federal confidentiality requirements upon admission to a sub- stance abuse treatment program or soon thereafter.
Authorization
Permission given to the health-care provider by the patient allowing the provider to disclose patient-specific health information.
Which bars a provider from receiving Medicare reimbursement either permanently or for a prescribed period of time?
Permissive and mandatory exclusion
Admissible
Pertinent and proper evidence. Rules of evidence determine if evidence is pertinent and proper. For example, in the context of medical records, the applicable rule of evidence is the hearsay rule.
Which statutes a category of confidentiality protection at the state level?
Physician-patient privilege
Stark I and Stark II laws were passed because _____.
Physicians were abusing the healthcare system by referring patients to services in which they (or family members) had a financial interest
Person who initiates a lawsuit is the _____.
Plaintiff
An order of preservation results in:
Preservation of electronic data
Order of preservation results in:
Preservation of electronic data
Compliance programs seek to _____.
Prevent and detect conduct that does not conform to applicable laws
qui tam action is defined as _____.
Private plaintiffs who sue on behalf of the U.S. government and who receive a portion of the recovered funds
Implied or tacit consent applies to _____.
Procedures involving little or no risk to the patient
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
Genetic Information Non-Discrimination Act (GINA) _____
Prohibits third-party payers from raising health insurance rates on a group or individual identified by genetic testing
Third parties have the right to access a person's information if _____.
Proper release of information is authorized
Federal regulations about the confidentiality of substance abuse records _____.
Protect substance abuse patients from being more vulnerable for seeking treatment compared with substance abuse patient who do not seek treatment
Americans with Disabilities Act requires employers to _____.
Provide qualified individuals with reasonable accommodations to performing essential job functions
Kickback violations occur when a(n) _____
Provider receives compensation for patient referrals to a specific facility
Stark violation occurs when _____.
Providers refer patients to a facility in which the provider holds a financial interest
Ethical guidelines have been established regarding patients with HIV and AIDS, which state that _____.
Providers' obligation of confidentiality does not cease with the death of the patient
Once a president has signed an executive order, it goes into effect as law when it has been _____.
Published in the Federal Register
Which statement is associated with criminal law?
Punishment may be a fine or imprisonment
substance abuse treatment release of information is invalid if it fails to include the _____.
Purpose of disclosure
Adoption records are considered confidential and can only be released _____.
Pursuant to legal procedures of the state in which the records are maintained
Continuum of ownership
Questions of ownership of health information range from the traditional view of the health-care provider having sole ownership of the medical record, to a joint patient-health-care provider ownership of the medical record, toward a trend placing health information in a trust capacity.
Patient rights involve the _____.
Recognition that the patient is entitled to determine for herself the extent to which she will receive or forego treatment
Computerized patient record
Records created, authenticated, stored, and retrieved by computers
Adoption records
Records of the individual placed for adoption. Access to adoption records is controversial. The competing issues involved in access are the interests of the biological parent(s) in placing the child up for adoption, often with the promise of confidentiality, and the interests of the adoptee for genetic information and information about his or her natural identity.
Which of the following are subject to strict legal requirements?
Records, regardless of format
Civil money penalty law may be applied to a violation, such as _____.
Recovering money damages for false or fraudulent claims requiring the provider to make restitution
Center for Medicare and Medicaid Services PEPP program _____.
Reduces Medicare payment error rates
When employees have password access to medical records, _____.
Released information is limited to that which has been authorized by the patient
Substance abuse health information is _____.
Released via specific authorization
Anti-kickback statutes were enacted to prevent _____
Remuneration for patient referrals
Health record banks
Repositories of personal health records in electronic form operated by governmental or commercial entities who serve as trusted custodians of the data contained in the health record bank.
Under the Americans with Disabilities Act, an employer is prohibited from _____.
Requesting an employee to pay for any accommodations required to perform the job if hired by the organization
In the context of billing fraud, which is associated with unbundling?
Separately billing laboratory tests to increase reimbursement from payers
Ethical challenges
Situations in which no clear cut "right" answer exists, and an individual is required to make a choice between two or more equally unfavorable alternatives or between a neutral alternative and a tempting but unfavorable alternative.
Which is an example of acceptable authentication of a medical record entry?
Specialist who authenticates his own dictated report electronically using a password
When records are modified or destroyed, it is referred to as:
Spoliation
Medicare conditions of participation require that home health ____
Staff maintain certain professional qualifications
In a negligence claim, the standard of care that considers the prevailing is the _____.
Standard that is higher
Ethical guidelines
Standards of conduct issued by professional organizations to guide their members' future course of action. These standards are sometimes used to establish the standard of care in a negligence action.
valid release of substance abuse treatment information includes a(n) _____.
Statement as to who is to receive the information
HIPAA regulations establish a "floor" of patient rights, which means _____.
States may enact legislation that provides for additional patient access to records
Good Samaritan statutes
Statutes that protect physicians and other rescuers from civil liability as a result of their actions or omissions in rendering emergency care, unless their actions or omissions were grossly negligent or intentionally injuring to the patient.
Open record statutes
Statutory provisions that address confidentiality requirements using a presumption of disclosure of information upon request, absent statutory exemption.
release of mental health information is _____.
Subject to strict rules regarding confidentiality, pursuant to individual state laws
Upcoding
Submitting a bill for a higher level of reimbursement than actually rendered in order to receive a higher reimbursement.
Unbundling
Submitting separate bills for each component of a procedure instead of using the proper procedural code for the entire procedure, resulting in a higher reimbursement rate to the health-care provider.
Which is an example of medical information associated with the health record?
Test results and operative reports
Deposition is a:
Testimony provided under oath outside of the courtroom
Voluntary testing
Testing with patient consent. Voluntary testing for HIV encompasses three areas: consent for testing, delivery of pretest information, and disclosure of test results.
constitutional basis for the right to privacy exists because _____.
The Supreme Court has applied privacy in the context of health information
Breach
The acquisition, access, use, or disclosure of protected health information in a manner that compromises the security or privacy of protected health information.
Disparagement
The belittling or criticizing of the skills, knowledge, or qualifications of another professional.
Reasonable diligence
The business care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances.
Health record content
The characteristics essential to constitute an adequate health record.
Conflict of interest
The clash between an individual's selfish interests and his or her obligation to an organization or group.
Rights
The concept of a just claim or entitlement, whether based on law, ethics, or morality, that others are obliged to respect.
Comparative justice
The concept referring to balancing the competing interests of individuals and groups against one another, with no independent standard used to make this comparison.
Values
The concepts that give meaning to an individual's life and serve as the framework for decision making.
Willful neglect
The conscious, intentional failure or reckless indifference to the obligation to comply with the administrative simplification provisions.
Improper disclosure
The disclosure of test results or other health information to a third party without the consent of the individual treated.
Invasion of privacy
The dissemination of information about another person's private, personal matters.
Comparative negligence
The doctrine adopted by most states that requires a comparison of the negligence of the defendant with the negligence of the plaintiff; the greater the negligence of the defendant, the lesser the level of care required of the plaintiff to permit him or her to recover. In other words, the plaintiff's negligence does not defeat his or her cause of action, but it does reduce the damages he or she is entitled to recover.
Compliance
The efforts to establish a culture that pro- motes prevention, detection, and resolution of instances of conduct that do not conform to applicable local, state, and federal laws and regulations.
Nonmaleficence
The ethical concept meaning the prohibition against doing harm; refers to the obligation to prevent evil or harm.
Beneficence
The ethical concept meaning the qualities of kindness, mercy, and charity; refers to the obligation to do good in all circumstances.
Distributive justice
The ethical concept of fair distribution of burdens and benefits using an independent standard.
Fidelity
The ethical concept of faithfulness, loyalty, and devotion to one's obligations or duties.
Autonomy
The ethical concept of independence, self- determination, or freedom; derives from two Greek words: autos, meaning self, and nomos, meaning governance.
Justice
The ethical concept referring to the obligation to be fair to all people; encompasses the ideas of fairness, honesty, and impartiality
Deontology
The ethical theory that asserts that ethical decision making is based on moral rules and unchanging principles that are derived from reason and can be applied universally; sometimes referred to as formalism or duty orientation.
Medical malpractice
The failure of a medical professional to follow a standard of care prevalent for his or her profession that results in harm to the patient. Legal theories supporting a medical malpractice lawsuit include negligence, res ipsa loquitur, failure to warn, vicarious liability, and corporate negligence.
Breach of duty of care
The failure to conform to a particular standard of care toward another. Such failure to conform will result in liability for harm sustained by another person.
Negligence
The failure to do something that a reason- able person would do in the same circumstances, or the doing of something a reasonable person would not do. Negligence is a wrong generally characterized by carelessness, inattentiveness, and neglectfulness rather than by positive intent to cause injury.
Breach of contract
The failure to perform according to the terms of the parties' agreement.
Ethics
The formal study of moral choices that conform to standards of conduct; derived from the Greek word ethos
Record retention policies
The general principles deter- mining the length of time medical records must be maintained by the health-care provider. The length of time is influenced by the needs of continuing patient care, education, research, and the law, to name a few.
Record destruction policies
The general principles determining the length of time medical records must be maintained before being destroyed. The length of time is determined by state statutes and state and federal regulations.
False arrest
The intentional detention or restraint of someone against his or her will with the intent to make an arrest or actually make the arrest.
False imprisonment
The intentional detention or restraint of someone against his or her will without legal justification. Such detention or restraint must be intentional, meaning that the person imposing confinement does so willfully.
Medical identity theft
The knowing transfer or use, without lawful authority, of health information and the identity of another person with the intent to commit, aid, or abet any unlawful activity that constitutes a violation of federal, state, or local law.
Identity theft
The knowing transfer or use, without lawful authority, of the identity of another person with the intent to commit, aid, or abet any unlawful activity that constitutes a violation of federal, state, or local law.
Emancipation
The legal ability of a minor to act as an adult when he or she has moved away from home and receives no support from his or her parents.
Legal health record
The legal business record generated at or for a health-care organization that is produced upon request.
Substituted consent
The legal doctrine that allows an authorized person to consent to or forgo treatment on the patient's behalf when the patient is not legally competent to provide consent.
Physician-patient privilege
The legal doctrine that prevents forced disclosure of, or testimony about, information obtained by the health-care provider during the course of treatment.
Informed consent
The legal doctrine that requires the health-care provider to disclose information to the patient about treatment options and risks so that the patient may knowledgeably consent to treatment.
Attorney-client privilege
The legal protection of communications between a client and his or her attorney, made in confidence for the purpose of obtaining legal advice.
Work-product privilege
The materials prepared in anticipation of litigation that may be shielded from discovery; sometimes referred to as the work-product doctrine.
Remedy
The means by which a right is enforced, an injury is redressed, and relief is obtained. Examples: damages; an injunction. (1) To redress; to make right; to correct; to rectify. (2) To compensate; to indemnify; to make whole.
Evidence
The means by which any matter of fact may be established or disproved. Such means may include testimony, documents, and physical objects. The law of evidence is made up of rules that determine what evidence is to be admitted or rejected in the trial of a civil action or a criminal prosecution and what weight is to be given to admitted evidence. Medical records may be used as evidence in civil or criminal court actions or in administrative agency proceedings.
Confidentiality
The obligation of the health-care provider to maintain patient information in a manner that will not permit dissemination beyond the health-care provider. The origin of confidentiality is found in the Hippocratic Oath.
Implied consent
The patient's consent to receive diagnostic or therapeutic treatment or procedures without expressing verbal or written action by the patient; often existing in situations in which a patient voluntarily submits to a procedure with apparent knowledge of that procedure and the procedure present slight or no apparent risk, such as taking the patient's pulse or temperature.
In the healthcare context, the distributive justice criterion of ability refers to the _____.
The patient's power to pay for healthcare procedures
Double-effect principle
The principle that recognizes that ethical choices may result in untoward outcomes.
Morals
The principles or fundamental standards of "right" conduct that an individual internalizes; derived from the Latin word mores.
Collective bargaining
The process by which a contract is negotiated between a union and employer setting forth the relationship between the two.
Certification process
The process by which the health information manager verifies that the copy of the health record provided in response to legal request is an exact duplicate of the original health record.
Employment
The process of providing work, engaging services or labor, and paying for the work performed.
Medical advice
The provision of a professional's opinion about what action an individual should or should not take with regard to their health.
Patient rights
The recognition that the patient is entitled to determine for him- or herself the extent to which he or she will receive or forego care and treatment.
Qualifications
The required education, degrees, certificates, and professional licenses along with the knowledge, skills, and ability to perform the essential functions of the job.
Privacy
The right to be left alone or the right to control personal information. The patient's right to privacy is the underpinning to legal protections for patient-specific health information.
Hearsay rule
The rule that hearsay testimony is not admissible unless it falls within an exception to the hearsay rule.
Medical staff privileges
The scope and limit of a physician's practice in a medical institution as defined by the institution's governing board.
Best-interest standard
The standard used to determine the best interest of an individual when the individual cannot make such a decision alone.
Administrative simplification
The streamlining and standardization of seemingly inefficient and non- uniform practices in the health-care industry; a goal of the Health Insurance Portability and Accountability Act (HIPAA).
Deeming authority
The substitution of complying with the requirements and standards of an accrediting organization in lieu of complying with the Medicare Conditions of Participation issued by the Centers for Medicare and Medicaid Services.
Damages
The sum of money that may be recovered in the courts as financial reparation for an injury or wrong suffered as a result of breach of contract or tort. Divided into three types: nominal, actual, punitive.
Which statement is true of a supreme court, except in New York State.
The supreme court is a court of last resort
Ethical theories
The systematic statements or plans of principles used to deal with ethical dilemmas.
Relators
The technical term used to describe the pri- vate plaintiffs who bring qui tam actions
Utilitarianism
The theory that proposes that everyone, including persons, organizations, and society in general, should make choices that promote the greatest balance of good over harm for everyone; sometimes referred to as consequentialism.
Breach of confidentiality
The unauthorized, unprivileged disclosure to a third party of nonpublic medical information that a physician or hospital has learned within a physician—patient or hospital—patient relationship.
Battery
The unconsented-to touching or striking of one person by another or by an object put in motion by him or her, with the intention of doing harm or giv ing offense. Battery is both a crime and a tort.
Medical abandonment
The unilateral severing, by the physician, of the physician—patient relationship without providing the patient with reasonable notice at a time when there is a necessity for continuing care.
Sexual harassment
The unwelcome sexual advances, requests for sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits, pro- motions, or continued employment.
Mail and wire fraud
The use of the U.S. Postal Service or commercial wire services for the advancement of a scheme relating to fraud.
Express consent
The verbal or written consent of a patient to receive diagnostic or therapeutic treatment or procedures.
Release of information
The written consent form that permits the dissemination of confidential health information to third parties. The components of a valid release of information are determined by state law and federal and state regulation.
Ethical challenges involve situations in which _____.
There are no clear cut right answers
Which is an example of financial information associated with the health record?
Third-party payer information
Which is categorized as a business associate, as defined by HIPAA regulations?
Third-party payers
Minimum necessary standard
This standard requires the health-care provider to make reasonable efforts to limit the patient-specific health information to the mini- mum necessary to accomplish the intended purpose of the use, disclosure, or request.
Impaired colleagues
Those colleagues who can no lon- ger function appropriately in the workplace due to sub- stance abuse, such as use of alcohol or drugs
Punitive damages
Those damages awarded above and beyond actual damages, often in instances where there is proof of outrageous, malicious, or intentional conduct; sometimes referred to as exemplary damages.
Exemplary damages
Those damages awarded above and beyond actual damages, often in instances where there is proof of outrageous, malicious, or intentional conduct; sometimes referred to as punitive damages.
Nominal damages
Those damages awarded for the vindication of a right in which minimal injury can be proved or in recognition of a technical invasion of a person's rights.
Compensatory damages
Those damages awarded to make the plaintiff whole and restore him or her to the position in existence before the injury; sometimes referred to as actual damages.
Actual damages
Those damages awarded to make the plaintiff whole and restore him or her to the position in existence before the injury; sometimes referred to as compensatory damages.
Enterprise content and record management
Those electronic records management principles (all of the dig- ital and analog records) and enterprise content management principles (the technology, tools, and methods) to capture, store, deliver, and preserve content across an enterprise.
Employer
Those persons, businesses, or organizations that provide the work, engage the services or labor, and pay for the work performed.
Nonintentional torts
Torts committed by persons who lack the intent to do something wrong.
Intentional torts
Torts committed by persons with the intent to do something wrong.
Physician-patient relationship
Traditionally, the cornerstone of U.S. health care. Begins when the patient requests treatment and the physician agrees to render the treatment. Exists as an express or implied contract.
disclosure of mental health records to _____ may be made without express patient authorization.
Treating healthcare personnel within the facility
Under stare decisis,
U.S. district courts are bound by decisions of both the U.S. Courts of Appeal and U.S. Supreme Court within the same geographic area
Assigning diagnostic and procedural codes to obtain better reimbursement alone is _____.
Unethical
Family Medical Leave Act (FMLA) provides for ____
Unpaid time off to adopt a child
Which includes concepts that give meaning to an individual's life and serve as the framework for decision making?
Values
concept of habitual truthfulness and honesty is called _____.
Veracity
ethics-based compliance program conforms to applicable laws through _____ because it is the right thing to do or because a cost-benefit analysis reveals it would be a sound business practice.
Voluntary compliance with local, state and federal laws and regulations
In the healthcare context, the distributive justice criterion of contribution refers to the _____.
What a person might be expected to contribute to society at a later date
Advance Directives
Written instructions recognized under state law, such as living wills or durable powers of attorney for health care, that relate to the kind of health care the patient wishes to have or not have if he or she becomes incapacitated.
Codes of ethics
Written lists of a profession's values and standards of conduct; sometimes referred to as codes of conduct.
Codes of conduct
Written lists of a profession's values and standards of conduct; sometimes referred to as codes of ethics.
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
statute of limitations is _____.
a fixed time period in which a lawsuit must be brought
Government's separation of powers include:
a system of checks and balances that is referred to as the separation of powers
Which is a direct identifier that must be removed from research subjects' records in order to comply with the use of a limited data set?
account number
An electronic case filing system (ECFS) is an automated system that:
allows the general public to search pleadings and testimony
U.S. Constitution can be modified with:
amendments
Chief executive branch of government issues executive orders that interprets:
and implements and/or gives administrative effect to provisions of the constitution or laws
Intentional tort may include a(n) _____.
assault
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
Personal jurisdiction refers to:
authority over parties involved
What is a court order?
authorization for disclosure that would otherwise be prohibited by statute or regulation
Prior to the development of the informed consent doctrine, which theory would have been used to hold a physician accountable for his actions?
battery
Legislative proposals are called:
bills
Unauthorized acquisition, access, use or disclosure of protected health information, which compromises the privacy or security of such information is called _____.
breach of confidentiality
Which allows a healthcare record to be admitted into evidence?
business record exception
Under the theory of failure to warn, the psychotherapist _____.
can warn an intended victim if the patient expresses the intent to do harm
When a health care facility files for bankruptcy and closes, a _____ is appointed to make decisions for the bankrupt health care provider.
case trustee
Which provides verification that the copy of the patient record is an exact duplicate of the original?
certification process
Reporting of public health threats include _____.
child abuse
Diversity jurisdiction is specific to:
citizens of different states as well as the federal courts
That part of the health record used for continuity of care is the _____ information
clinical
Which is a written list of a profession's values and standards of conduct?
code of ethics
written list of a profession's values and standards of conduct would best be described as the _____.
code of ethics
Subpoena ad testificandum _____.
commands the appearance of a witness to provide testimony
right to bring a lawsuit for damages related to breach of confidentiality is protected under _____.
common law
Written document that describes the grounds of jurisdiction, plaintiff's claim, and demand for relief is called the _____.
complaint
authorization for use or disclosure of patient-specific health information that has been combined with any other document is called a(n) _____ authorization.
compound
According to the Constitution, which branch has been granted the power to establish lower federal courts.
congress
Which theory applies to a patient who refuses antibiotics for an upper respiratory infection and who later acquires pneumonia?
contributory negligence
Breach of duty owed directly to a patient by a hospital is best described as _____ negligence.
corporate
Jurisdiction for medical malpractice cases:
could be either state or federal
Burden of proof is "beyond a reasonable doubt" during a _____ trial.
criminal
Defendant who has been found guilty in a _____ case may appeal the verdict.
criminal
Plaintiff is always the state or federal government in _____ law.
criminal
Punishment associated with _____ law may include fines and/or imprisonment.
criminal
When a party submits evidence of compliance with accrediting standards in lieu of evidence of compliance with Medicare, it is referred to as which of the following?
deeming authority
Person being sued is called the _____.
defendant
Notice of breach of confidentiality must include a(n) _____
description of types of unsecured protected health information involved
Medical abandonment may be applied to a patient who was _____.
discharged with continued chest pain and who later died of a heart attack upon returning to her home
Which is sometimes considered as an issue related to the financial controls imposed by prospective payment systems and health maintenance organizations?
distributive justice
Which is a concept that describes the requirement to anticipate the need for data in a court action?
duty to preserve
FRCP governs all forms of discovery performed in federal court, including seeking information that is stored electronically in any medium, which is called _____.
e-discovery
Under distributive justice, the willingness to comply with instruction or medical advice is best described as _____.
effort
Which defines the process of providing work, engaging services or labor, and paying for the work performed?
employment
Tort law:
encompasses the rights and duties that exist between parties that are independent of a contract
Healthcare records are considered hearsay evidence because _____.
entries are not made under oath at the time they were documented
concept of rights _____.
erives from the concept of justice in that both involve obligations
Expert testimony is used in a malpractice case to _____.
establish a breach in the standard of care
Which legal use of health care information directly impacts patient care?
establishing standards of care
Which is established within an organization or profession to evaluate current guidelines and establish new guidelines?
ethics committee
Consideration is an element of contract law that refers to _____.
exchange from one party in return for performing contractual obligations
Authority for release of information can be granted by a(n) _____.
executor of an estate
Administrative Procedure Act (APA) governs the way in which administrative agencies of the _____ government may propose and establish regulations.
federal
Which may issue a subpoena?
federal court clerks
Executive orders have the effect of law after being published (in the case of the federal system) in the:
federal register
Felony is defined as a crime ____
grave or serious natue
Patient rights _____.
have been formalized into statutory provisions by some states
In the context of billing fraud, upcoding is submitting a bill for a higher level of reimbursement than actually rendered in order to receive _____.
higher reimbursement rates
Which relationship begins with the credentialing process?
hospital-physician
Legislative branch of government:
includes the Senate and the House of Representatives
Constitution is a set of fundamental principles or established precedents according to which a state or other organization is governed. Thus, it:
is considered the fundamental law of a nation or state
Unemployment insurance _____
is funded through a tax on employers
Public law:
is subdivided into administrative, constitutional and criminal law
Authority by which courts and judicial officers may hear and decide a case is called _____.
jurisdiction
Standards for human behavior are established through _____
laws
Standards for human behavior are established through _____.
laws
Which are employed by a service firm and assigned to work at a business or an organization?
leased
Stages through which a lawsuit passes is called the _____ process
legal
Quasi-legal requirements may involve which of the following:
licensure
Insurance companies may cause an ethical dilemma by requiring _____.
limitations of inpatient hospitalization stays
What is the action of a party who possesses data to make efforts to prevent routine destruction of electronically stored information?
litigation hold
What term refers to the actions of a party who processes data to make efforts to prevent routine destructions and preserve electronically stored data?
litigation hold
Zoning, building, or public safety ordinances are examples of laws passed at:
local level
In deciding a dispute, the court or judicial branch:
may apply the doctrines of stare decisis and res judicata
State laws regarding substance abuse records _____.
may be equal to, less restrictive than, or more restrictive than federal law
Health record become admissible to court after:
meeting foundation and trustworthiness requirements
Consensus ad idem is Latin for the element of a contract associated with _____.
meeting of the minds
specialized patient record contains diagnoses regarding:
mental illness
Which is the unseen information that is located in common text files, such as that which can indicate when the document was created?
metadata
notice regarding redisclosure of information of substance abuse treatment records _____.
must accompany any disclosure
Res ipsa loquitur is a type of _____ tort.
nonintentional
Which is a letter sent by an adversary in a court case that explains the need to preserve electronic evidence?
notice of preservation
notice of preservation _____.
notifies the opposing party of the need to preserve relevant electronic evidence
Privacy refers to the right to be left alone while confidentiality is the _____.
obligation of the healthcare provider to protect patient information
Laws passed at the local level are called _____.
ordinances
According to HIPAA, the _____ has the right to access patient information in the complete medical record.
patient
Health care information is owned by the _____.
patient
Which was created by statute and used to prevent the forced disclosure of, or testimony about, information obtained by the health care provider during the course of treatment?
physician-patient privilege
Conflicts of interest that appear to be inappropriate but do no harm are described as _____
potential
Under civil law, the burden of proof is described as a _____.
preponderance of the evidence, which is defined as "more likely than not"
Hospital-patient relationship is established when a patient _____.
presents either voluntarily for care or in an emergency situation
Which consists of the body of rules and principles that govern the rights and duties between parties?
private/civil
Which is the inspection and/or copying of documents or other physical evidence upon written request?
production of documents and things
Malpractice refers to _____.
professional misconduct
Which of the following is associated with the Bill of Rights?
protects the rights to freedom of speech and religion
Under res ipsa loquitur the _____.
provider had exclusive control over the instrument involved in the injury
Which describes the necessity for a hospital to follow its own medical staff by-laws of policy?
quasi-legal requirement
double-effect principle refers to _____.
recognizing that ethical choices may result in adverse outcomes
When information concerning HIV/AIDS, mental health, and substance abuse is released to a third party, a _____ prohibits sharing the information with yet another third party unless the patient signs an authorization to release the information.
redisclosure statement
physician-patient relationship is established when the patient _____.
requests health care and the physician agrees to render health care
release of information _____.
requires the express consent of the patient
Good Samaritan statutes protect _____.
rescuers from claims related to the administration of unauthorized treatment
Medical staff privileges include ____.
scope of physician's practice
Which occurs when the court directs a person or organization to appear to explain why the court should not take a proposed action?
show cause order
Under which jurisdiction is the following categorized: most issues involving the regulation of trades and professions.
state courts
Addition to supplying the record, the person who possesses the record could be compelled to deliver it at a certain time and place if the request is accompanied by a:
subpoena duces tecum
What is command ordered by the court, which requires the appearance of a witness to provide testimony?
subpoena testificandum
Which subcategory of criminal law defines specific offenses?
substantive
Criminal law is subdivided into _____ categories.
substantive and procedural
In Mordecai vs. Blue Cross/Blue Shield of Alabama, the court determined that _____.
the insured had the right to proceed against the insurance company for breach of contract to determine whether it had correctly determined that patient care was not medically necessary
Nonmaleficence is defined as _____.
the prohibition against doing harm and an obligation to maximize the good
When parties to a dispute come together to present evidence in court, the formal setting with authority to adjudicate claims or disputes is called a bench or jury _____.
trial
Good Samaritan laws provide legal protection for _____ treatment
unauthorized
Which is an exclusion to physician-patient privilege rules?
when privilege conceals child abuse
What is a request of admission?
written questions presented to a party to obtain certain facts
Answer to a complaint that is made by the defendant is called the _____.
written response
Spoliation is _____.
wrongful destruction or alteration of evidence
Spoliation of evidence occurs as a result of:
wrongful destruction or alteration of evidence and/or failure to preserve data
