RHIT Legal
A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased? 14 12 11 13
14 2,540 + 400 = 2,940 inches needed 36 × 6 = 216 inches per unit 2,940 (inches needed) divided by 216 (inches per unit) = 13.61 shelves You must buy 14 units because you cannot purchase a 0.14 filing shelf.
Southwest Health System has numerous semiretired staff. The Human Resources Department has provided training regarding the Age Discrimination in Employment Act (ADEA). They emphasized that it protects employees and applicants between what ages? 62 and 85 50 and 75 45 and 99 40 and 70
40 and 70
According to AHIMA and AHA guidelines, which of the following would be an acceptable authorization for release of information from the medical record of an adult, mentally competent patient hospitalized from 4/16/2011 to 5/10/2011? An authorization dated 2/15/2013 and presented 1/10/2013 3/10/2013 and presented 5/15/2013 5/09/2013 and presented 1/15/2014 7/10/2013 and presented 7/15/2013
7/10/2013 and presented 7/15/2013
According to AHIMA and AHA guidelines, which of the following would be an acceptable authorization for release of information from the medical record of an adult, mentally competent patient hospitalized from 4/16/2011 to 5/10/2011? An authorization dated 5/09/2013 and presented 1/15/2014 7/10/2013 and presented 7/15/2013
7/10/2013 and presented 7/15/2013
Which of the following measures should a health care facility incorporate into its institution-wide security plan to protect the confidentiality of the patient record? locked access to data processing and record areas use of unique computer passwords, key cares, or biometric identification verification of employee identification All of these answers apply.
All of these answers apply.
Puget Sound Health System has set hiring goals and taken steps to guarantee equal employment opportunities for members of protected groups (e.g., American Indians, veterans, etc.). It is complying with Civil Rights Act. Minority Hiring Act. Equal Pay Act. Affirmative Action.
Civil Rights Act.
In which type of facility does the Privacy Act of 1974 permit patients to request amendments to their medical record? Department of Defense health care facility private proprietary health care facility mental health and chemical dependency facility university-based teaching facility
Department of Defense health care facility
What advice should be given to a physician who has just informed you that she just discovered that a significant portion of a discharge summary she dictated last month was left out? Squeeze in the information omitted by writing in available spaces such as the top, bottom, and side margins. Inform the physician that nothing can be done about the situation. Redictate the discharge summary and replace the old one with the new one. Dictate the portion omitted with the heading "Discharge Summary-Addendum" and make a reference to the addendum with a note that is dated and signed on the initial Discharge Summary (e.g., "9/1/11-See Addendum to Discharge Summary"-Signature).
Dictate the portion omitted with the heading "Discharge Summary-Addendum" and make a reference to the addendum with a note that is dated and signed on the initial Discharge Summary (e.g., "9/1/11-See Addendum to Discharge Summary"-Signature).
Your HIS Department receives an authorization for Sara May's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. What action is appropriate according to HIPAA privacy rules? Honor the authorization since the patient obviously approves of the release. Contact the patient to get permission to respond. Do not honor because the authorization is invalid. Contact the attending physician for permission to respond.
Do not honor because the authorization is invalid.
You are interviewing a candidate for a subpoena clerk position in the release of information section. Which of the following is the LEAST appropriate information to ask an interviewee to provide? Please provide a copy of your most recent CE certificate and AHIMA membership. Do you have transportation for attendance at depositions and court? Do you have family responsibilities that would keep you from remaining at a trial? Please share an experience where you had to determine applicable state law.
Do you have family responsibilities that would keep you from remaining at a trial?
Which of the following acts was passed to stimulate the development of standards to facilitate electronic maintenance and transmission of health information? Health Insurance Portability and Accountability Act Conditions of Participation Health Insurance for the Aged Hospital Survey and Construction Act
Health Insurance Portability and Accountability Act
Which of the following statements is correct regarding HIPAA preemption analysis? State law regarding a patient's right to health care information privacy can never prevail over the HIPAA federal rule. If the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the state law prevails. Even if the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, the HIPAA federal rule will still prevail. If a state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the courts must decide which shall prevail.
If the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the state law prevails.
The legislation that required all federally funded facilities to inform patients of their rights under state law to accept or refuse medical treatment is known as durable power of attorney. living wills. advance directives. Patient Self-Determination Act.
Patient Self-Determination Act.
If the patient record is involved in litigation and the physician requests to make a change to that record, what should the HIM professional do? Notify the patient. Refer request to legal counsel. Say the record is unavailable. Allow the change to occur.
Refer request to legal counsel.
While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation? Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record. Tell the employee to leave the report in the record. Refer this record to the Risk Manager for further review and removal of the incident report. Remove the incident report and send it to the patient.
Refer this record to the Risk Manager for further review and removal of the incident report.
Medical record information may be exempt from the Freedom of Information Act requirements if the request for information meets the test of being an unwarranted invasion of personal privacy. Which of the following is NOT one of the conditions of the test? The information must be contained in a personal, medical, or similar file. The severity of the invasion must outweigh the public's interest in disclosure. The information is generated from federally funded research conducted by a private health care organization. Disclosure of the information constitutes an invasion of personal privacy.
The information is generated from federally funded research conducted by a private health care organization.
Which would be the better "best practice" for handling fax transmission of a physician's orders? Faxed orders should be placed on the patient's chart immediately upon receipt after the head nurse signs the orders. Faxed orders should never be accepted. Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required period. Wait 24 hours before placing faxed orders on the patient's chart to ensure that the orders are legitimate.
Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required period
Which would be the better "best practice" for handling fax transmission of a physician's orders? Faxed orders should be placed on the patient's chart immediately upon receipt after the head nurse signs the orders. Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required period. Wait 24 hours before placing faxed orders on the patient's chart to ensure that the orders are legitimate.
Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required period.
The protection of a patient's health information is addressed in each of the following EXCEPT Drug Abuse and Treatment Act. Health Insurance Portability and Accountability Act. U.S. Patriot Act. Privacy Act.
U.S. Patriot Act.
One of your new employees has just completed orientation, receiving basic HIPAA training. You are now providing more specific training related to her job. She asks whether the information she provided during the hiring process, as well as benefits claims, are also protected under HIPAA. Which of the following can you assure her that the Human Resources Department protects? benefits enrollment Employee Assistance Program contacts OSHA information all personal health information (PHI)
all personal health information (PHI)
The extent to which the HIPAA privacy rule may regulate an individual's rights of access is not meant to preempt other existing federal laws and regulations. This means that if an individual's rights of access are greater under another existing federal law, HIPAA can obstruct freedoms of the other federal law when using electronic health records. are refused by a federal facility, HIPAA must also refuse the individual of the access. are less under another existing federal law, HIPAA must follow the directions of that law. are greater under another applicable federal law, the individual should be afforded the greater access.
are greater under another applicable federal law, the individual should be afforded the greater access
One best practice to follow in order to establish safeguards for the security and confidentiality of a patient's information when a person makes a request for his or her records in person is to refer the requester to the facility's attorney. refuse the request. ask the requester for identification and the request in writing. charge an exorbitant fee.
ask the requester for identification and the request in writing.
Yanique is a new supervisor at a mental health facility. She discovers that one of her employees has shared her password with a coworker. This action violates policies and procedures and is the first occasion of difficulty with this employee. Disciplinary action should be taken by referring the action to Human Resources. waiting for another occurrence to act. immediately dismissing the employee. asking for guidance from Human Resources and then acting.
asking for guidance from Human Resources and then acting.
A patient was treated for meningitis at age 3 (15 years ago). The patient is now 18. The patient's attorney is requesting information on the admission. You tell the clerk the information is no longer available because your facility retains information for 10 years after the last patient visit. available, but the patient's parents will have to sign a consent for you to release it. available, and the patient may sign consent to release the information in the record. available, but the attorney will have to obtain a court order before you will release it.
available, and the patient may sign consent to release the information in the record.
A record that has been requested by subpoena duces tecum is currently located at an off-site microfilm company. By contacting the microfilm provider, you learn that the microfilm is ready and the original copy of the record still exists. What legal requirement would compel you to produce the original record for the court? motion to quash subpoena instanter best evidence rule hearsay rule
best evidence rule
Employers may be able to demonstrate that age is a reasonable requirement for a position. Such an exception to the Age Discrimination in Employment Act (ADEA) is called a bona fide occupational qualification. essential element for employment. job description essential. there is no such exception to ADEA.
bona fide occupational qualification.
To be admitted into court as evidence, medical records or health information are introduced as torts or contracts. business records or exception to hearsay rule. privileged information. product liability.
business records or exception to hearsay rule.
When substituting a photocopy of the original record in response to legal process, which of the following can be helpful in convincing the court to accept the photocopy as a true and exact copy of the original? certificate of authentication correspondence from the attending physician consent from the hospital administrator consent from the patient
certificate of authentication
A health care organization's compliance plans should not only focus on regulatory compliance, but also have a component that increases the security of medical records. strong personnel component that reduces the rapid turnover of nursing personnel. substantial program that increases the availability of clinical data. coding compliance program that prevents fraudulent coding and billing.
coding compliance program that prevents fraudulent coding and billing.
Willful disregard of a subpoena is considered contributory negligence. abuse of process. breach of contract. contempt of court.
contempt of court
When a health care facility fails to investigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the health care facility can be held liable under respondeat superior. general negligence. corporate negligence. contributory negligence.
corporate negligence.
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets forth all of the following EXCEPT covered entities provide every patient with its annual business report. covered entities' obligations for protecting the patient's PHI. how covered entities may use and disclose PHI. patient's rights regarding the covered entities' uses and disclosures.
covered entities provide every patient with its annual business report.
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets forth all of the following EXCEPT covered entities provide every patient with its annual business report. covered entities' obligations for protecting the patient's PHI. how covered entities may use and disclose PHI. patient's rights regarding the covered entities' uses and disclosures.
covered entities provide every patient with its annual business report.
A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors? volume of research readmission rate statute of limitations department staffing
department staffing
Case Study #2 You are the Director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions. Referring to Case Study #2, the sworn verbal testimony you are asked to provide is called a(n) deposition. court order. physical and mental examination. interrogatory.
deposition
Case Study #2 You are the Director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions. Referring to Case Study #2, what phase of the lawsuit are you involved in? pretrial conference trial discovery appeal
discovery
Mandatory reporting requirements for vital statistics generally do not require authorization by the patient. require authorization by the payer. require authorization by the physician. do not apply to health care facilities.
do not require authorization by the patient.
Which of the following elements of negligence must be present in order to recover damages? duty of care; breach of duty of care; value attached to injury is greater than a certain value (ordinarily $1,000); provisions of the HIPAA privacy rule have been met duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm breach of duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000); provision of HIPAA privacy rule have been met duty of care; breach of the duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000)
duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm
All of the following are elements of a contract EXCEPT price/consideration. offer/communication. duty. acceptance.
duty.
Human Resources provide training for new supervisors. It includes discussion of the Equal Pay Act, which was passed to eliminate discrimination based on which of the following? employee gender personal productivity, such as in an incentive compensation system merit of the employee seniority of the employee
employee gender
A major consideration in a hospital or facility closure is to seek approval for destruction of all records with a last date of treatment over 3 years ago. ensure that authorized parties have access to the information as provided by law. notify all patients to pick up their original records by the date of closure. arrange for donating the records to an HIA/HIT education program for student use.
ensure that authorized parties have access to the information as provided by law.
A written consent from the patient is required from which of the following entities in order to learn a patient's HIV status? health care workers emergency medical personnel insurance companies spouse or needle partner
insurance companies
Under traditional rules of evidence, a medical/health record is considered ______________ and is ___________________ into evidence. hearsay; admissible reliable; admissible reliable; inadmissible hearsay; inadmissible
hearsay; admissible
What type of testimony is inappropriate for a health information manager serving as custodian of the record when he or she is called to be a witness in court? interpretation of documentation in the record whether the record is in the practitioner's possession title and position held in the health care facility whether the medical record was made in the usual course of business
interpretation of documentation in the record
A patient's husband slipped and fell in your HIM reception area and now he is suing the facility. You have to prepare detailed written answers to a long list of questions and send them to your hospital attorney. You will spend the afternoon working on allocutions. depositions. interrogatories. affidavits.
interrogatories
Case Study #2 You are the Director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions. Referring to Case Study #2, the written answers to questions you have been asked to provide are known as a(n) deposition. court order. interrogatory. physical and mental examination.
interrogatory
An improper disclosure of patient information to unauthorized individuals, agencies, or news media may be considered a(n) libel. defamation. slander. invasion of privacy.
invasion of privacy.
With regard to confidentiality, when HIM functions are outsourced (i.e., record copying, microfilming, or transcription), the HIM professional should confirm that the outside contractor's is contractually bound to handle confidential information appropriately by means of a signed business associate agreement. is located in an easy to find place. costs are not prohibitive, thus compromising confidentiality. hours of operation permit easy access by all health care providers.
is contractually bound to handle confidential information appropriately by means of a signed business associate agreement.
Dr. Roberts, and Nurse Parrish, have had a bad relationship for years. One day Dr. Roberts discovered that the PT evaluation he had ordered for a patient had not been performed. Dr. Roberts placed the blame for the missed evaluation with Nurse Parrish and wrote in the patient's medical record that Nurse Parrish was incompetent . Nurse Parrish countered by telling the medical personnel that Dr. Roberts was responsible for the needless suffering of countless patients. Referring to Case Study #1, the written statement by Dr. Roberts about Nurse Parrish's professional competence in the patient's medical record can constitute perjury. slander. libel. defamation.
libel.
All of the following need a proper authorization to access a patient's health information EXCEPT FBI agents. IRS agents. local and state law enforcement officers. medical examiners or coroners.
medical examiners or coroners.
Many states have recognized a minor's right to seek treatment without parental consent in all of the following situations EXCEPT a(n) emancipated minor seeking treatment for breast enlargement. minor seeking treatment for alcohol and substance abuse. minor seeking treatment for breast reduction. minor seeking treatment for a sexually transmitted disease.
minor seeking treatment for breast reduction.
A 73-year-old male was admitted to the Sunset Nursing Facility with senility, cataracts, and S/P cerebrovascular accident with right-side hemiplegia. On his second day at the facility, the resident was discovered to have extensive thermal burns on his buttocks and legs by one of the facility's attendants. Referring to Case Study #3, the resident's family brought legal action against the nursing facility for medical abandonment. vicarious liability. assault and battery. negligence.
negligence.
vSubstance abuse records cannot be redisclosed by a receiving facility to another health care facility unless the patient expires at the receiving facility. charge nurse signs the release form. patient gives written consent. physician signs the DNR form.
patient gives written consent.
It is common practice to forgo patient authorization for the release of information when the patient is incompetent. patient has a direct transfer from the hospital to a long-term care facility. patient is an employee. patient is a physician.
patient has a direct transfer from the hospital to a long-term care facility.
The ownership of the information contained in the physical medical/health record is considered to belong to the physician. patient. hospital. insurance company.
patient.
Under the Americans with Disabilities Act (ADA), prior to employment, it is illegal to require a math aptitude test. physical exam. typing skill test. coding proficiency test.
physical exam.
Which of the following HIPAA components would the general New Employee Orientation training most likely cover? job-specific training (e.g., patient's right to amend record) business associate agreements marketing issues physical/workstation security
physical/workstation security
As a general rule, a person making a report in good faith and under statutory command (e.g., on child abuse, communicable diseases, births, deaths, etc.) is subject to penalties imposed by state law. protected. not protected from liability claims. subject to penalties imposed by federal law.
protected.
In which of the following circumstances would release of information without the patient's authorization be permissible? release to insurance companies release to an attorney release to third-party payers release to state workers' compensation agencies
release to state workers' compensation agencies
Dr. Roberts and Nurse Parrish have had an bad relationship for years. When Dr. Roberts discovered that the PT evaluation he had ordered had not been performed he blamed the missed evaluation on Nurse Parrish. Dr. Roberts wrote in the patient's MR that Nurse Parrish failed to properly order the PT eval because she was incompetent. After having read Dr. Roberts's note, Nurse Parrish made a disparaging remark about Dr. Roberts to the medical personnel. Nurse Parrish stated that Dr. Roberts was the one who was incompetent. Referring to Case Study #1, the oral statement by Nurse Parrish about Dr. Roberts's professional practices at the nurses' station can constitute perjury. slander. libel. defamation.
slander.
The fee paid for reimbursement for expenses incurred from providing health information whether for subpoena or reproduction by health care providers is determined by the plaintiff and defendant lawyers. American Health Information Management Association. statute or court rules. hospitals and lawyers.
statute or court rules.
A written authorization from the patient releasing copies of his or her medical records is required by all of the following EXCEPT a physician requesting copies from another physician. the hospital attorney for the facility where the patient is treated. the patient's attorney. an insurance company.
the hospital attorney for the facility where the patient is treated.
In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to the patient's spouse. a health care provider interested in the case. the quality assurance committee for review purposes. a third-party payer with a direct interest in the case.
the quality assurance committee for review purposes.
Consent forms may be challenged on all the following grounds EXCEPT the treating physician obtained the patient's signature. it is written in a language that the patient could not understand. the signature was not voluntary. wording was too technical.
the treating physician obtained the patient's signature.
Internal disclosures of patient information for patient care purposes should not be granted to a family member who is a registered nurse at the facility. to the attending physician. on a need to know basis. to the facility's legal counsel.
to a family member who is a registered nurse at the facility.
According to AHIMA's Position on Transmission of Health Information, the health information manager should engage in all of the following to ensure that information is properly sent via facsimile transmission EXCEPT encrypt the data if public channels are used for electronic transmittal. to preprogram into the machine the number of destination sites. ask the sender to contact the recipient prior to and after transmission. to always follow up by sending the original record by mail.
to always follow up by sending the original record by mail.
The HIPAA Privacy and Security Rule requires that training be documented. What methods of documenting training efforts need to be used? signed confidentiality statements training content, training dates, and attendee names meeting handouts and minutes retention of training aids and handouts
training content, training dates, and attendee names
Which of the following health care systems have to comply with the requirements of the Freedom of Information Act? single-day surgery clinics private hospitals physicians' offices veterans' hospitals
veterans' hospitals
