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Law and Ethics for the Health Professions 6th Edition Judson Harrison Test Bank

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Law and Ethics for the Health Professions 6th Edition Judson Harrison Test Bank

ISBN-13: 978-0073374710

ISBN-10: 0073374717

Description

Law and Ethics for the Health Professions 6th Edition Judson Harrison Test Bank

ISBN-13: 978-0073374710

ISBN-10: 0073374717

 

 

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Free Nursing Test Questions:

 

 

Multiple Choice Questions

  1. A nurse carefully documents all pertinent patient information in the patient medical record. Which of the following is true of this document?
    A. Medical records are voluntary and are not required by licensing authorities.
    B. Medical records provide documentation of a patient’s health care from birth to death.
    C. Medical records do not serve as legal documents in lawsuits.
    D. Medical records can be changed as a patient’s condition improves or worsens.

 

  1. A subpoena duces tecum is ordered during a malpractice trial. What does this subpoena provide as evidence?
    A. Expert witness testimony
    B. Fact witnesses
    C. Medical records
    D. Telephone transcripts

 

  1. Medical records are often subpoenaed for court trials. Which of the following is true regarding the use of medical records as evidence?
    A. If there is no entry in the medical record it cannot be presumed that it was not done.
    B. Records for legal purposes must be kept on paper.
    C. Medical records do not prevail over a patient’s recollection of events during a trial.
    D. What is omitted from the record may be as important to the trial as what is included.

 

  1. The Five Cs are used to describe the attributes of entries in a patient’s medical record. Which of the following is not one of the 4Cs?
    A. Concise
    B. Complete
    C. Chronologically ordered
    D. Clean

 

 

  1. Which of the following should not be included in a patient’s medical record?
    A. Personal judgments
    B. Times of arrival for appointments
    C. Social security number
    D. Driver’s license information

 

  1. A plastic surgeon documents the before and after pictures of a patient after receiving a signed consent from the patient. Which of the following torts might occur from photographing a patient without proper consent?
    A. Assault
    B. Defamation
    C. Invasion of privacy
    D. Negligence

 

  1. A plastic surgeon routinely photographs patients to document care. Which of the following accurately describes information that should be included on the consent form for this type of photography?
    A. The patient understands that ownership rights to the photos belong to the patient.
    B. The patient understands that the photos will be kept for an undetermined time period.
    C. The patient understands that he or she cannot view the photographs.
    D. The patient understands that authorization must be given to release photos outside the facility.

 

  1. Under which of the following circumstances should a separate consent form be obtained to use patient images?
    A. When they will be used for teaching purposes.
    B. When they will be used to document routine care.
    C. When they will be used to document a new procedure.
    D. When they will be used to document before and after patient conditions.

 

 

  1. A nurse documenting patient care makes an error when recording the vital signs. Which of the following is the correct guideline for correcting errors in a patient’s medical record?
    A. Black out the information with a permanent magic marker and write above the entry.
    B. Draw a line through the error so that it is still legible and write above or below the line.
    C. Use correction fluid to white out the error and write the entry on top of the white-out.
    D. Do not place the correction on a separate piece of paper, rather write in the margins of the original copy.

 

  1. A physician is documenting patient information on the medical record and receives a phone call that distracts him, causing him to record the wrong medication prescription. Which of the following is a correct guideline for correcting the medical record error?
    A. Do not make a change in the record without noting the reason for it.
    B. Enter the date and time and have the patient initial the correction.
    C. Ask two other staff members to initial the correction to the record.
    D. Put all corrections on a separate piece of paper and attach to the back of the record

 

  1. A physician has a private practice employing a physician assistant and two nurses. The physician also has hospital privileges at a nearby facility. Who owns the medical records generated by his office?
    A. The patient
    B. The hospital
    C. The nurses
    D. The physician

 

  1. A hospital maintains medical records on all patients who are treated. Who owns the information contained in the medical record?
    A. The patient
    B. The treating physician
    C. The hospital
    D. The nurse

 

 

  1. The doctrine of professional discretion pertains to medical record keeping. Which of the following does this doctrine occasionally uphold in court?
    A. Patients should be able to obtain access to or copies of their medical records according to state law.
    B. It is up to the discretion of the physician whether or not to allow all patients access to their medical records.
    C. In cases where viewing the medical record may cause harm to patients, it is up to the health care provider whether or not to allow them access to the medical record.
    D. It is up to the discretion of the facility whether or not to allow patients access to their medical records.

 

  1. Which of the following legislation states that patients that ask to see and/or copy their medical records must be accommodated with a few exceptions?
    A. FDA
    B. JACHO
    C. HIPAA
    D. OSHA

 

  1. A physician in a private practice examines a patient who is being considered for a job with a pharmaceutical company. The prospective employer pays for the physical. Who is the owner of the medical record in this example?
    A. The patient
    B. The physician
    C. The prospective employer
    D. The government

 

  1. As a protection in the event of litigation, records should be kept until the applicable statute of limitations period has elapsed. What is the usual timeframe for this period of time?
    A. 1 to 5 years
    B. 2 to 7 years
    C. 5 to 10 years
    D. 12 to 20 years

 

 

  1. Which of the following describes the proper protocol for the release of medical records?
    A. Medical records may be released to third party payers without patient consent.
    B. When patient information is requested the entire medical record should be released.
    C. Signed consent for medical records is not required for use in a lawsuit.
    D. When medical records are subpoenaed, the patient should be notified in writing.

 

  1. Which of the following occurs with the medical record when a patient transfers to another physician?
    A. The original medical record is sent to the new physician.
    B. The patient signs an authorization to release his or her records to the new physician.
    C. A new medical record is started that does not contain the old record information.
    D. The old medical record is destroyed.

 

  1. In which of the following cases would patient authorization for release of his or her medical record be waived?
    A. For an insurance claim
    B. When transferring to another physician
    C. When a subpoena duces tecum is issued
    D. When a patient dies

 

  1. A physician has an obligation to his or her patient based on trust and confidence. What is the term for this obligation?
    A. Fiduciary duty
    B. Breach of confidence
    C. Consent
    D. Caring relationship

 

  1. A physician receives a subpoena for a patient’s medical records to help determine an award in a workmen’s compensation case. How would the physician handle this request?
    A. Send the entire original medical record to the court.
    B. Photocopy the medical record and send it to the plaintiff.
    C. Photocopy the medical record and send to the attorney who issued the subpoena.
    D. Send a release of information form to the patient to sign for release of the records.

 

 

  1. When a physician is sued for malpractice, whom might the responsibility to comply with a subpoena to produce medical records fall?
    A. The nurse
    B. The physician
    C. The patient
    D. The medical office employee

 

  1. A subpoena duces tecum is issued for the medical records of a patient who is suing the physician for malpractice. Which of the following is a guideline for sending this information?
    A. Verify that the patient named was not a patient of the physician.
    B. Notify the insurance company officials and have them notify the physician.
    C. Finish or change any subpoenaed records that are not complete or up to date.
    D. Offer sworn testimony regarding the record if instructed to do so by the court.

 

  1. When a patient medical record is subpoenaed by the court, which of the following information must be listed on the subpoena?
    A. The name and phone number of the judge
    B. The trial date and time
    C. The physician’s license number
    D. The formal complaint of the patient

 

  1. Which of the following information is the federal statute known as the Confidentiality of Alcohol and Drug Abuse, Patient Records designed to protect?
    A. Patient treatment
    B. Patient convictions
    C. Patient behavior
    D. Physician liability

 

 

  1. The person in charge of medical records for a physician’s office is preparing to release medical records requested by an insurance company. Which of the following is a recommended guideline for this procedure?
    A. Receive a verbal authorization from the patient prior to releasing the patient record.
    B. Verify the patient’s name, address, and date of birth on the authorization.
    C. Release the entire record, not just the information specifically requested.
    D. Warn patient that once authorized, consent to release information cannot be rescinded.

 

  1. Which of the following is not a requirement when a request for information comes into the medical office from insurance companies, physicians, or other sources?
    A. It must be witnessed and dated.
    B. It must include the name, address, and signature of the party releasing information.
    C. It must list the purpose for which the data will be used.
    D. It must state that the information will not be used in court trial

 

  1. What is the legal term for the permission a patient gives for a physician to examine him or her, to perform tests, and/or treat a medical condition?
    A. Fiduciary duty
    B. Confidentiality
    C. Consent
    D. Authorization

 

  1. Which of the following is an example of implied consent?
    A. A patient makes an appointment for an examination.
    B. A patient signs an informed consent for surgery.
    C. A patient states that he or she will cooperate with diagnostic testing.
    D. A patient states that he or she will take medications prescribed.

 

  1. For which of the following examples would implied consent not be legally appropriate?
    A. A physician treats a patient for prostate cancer.
    B. A patient provides a urine specimen to check for UTI.
    C. A patient agrees to a test for HIV.
    D. A patient has his blood pressure taken during an examination.

 

 

  1. The doctrine of informed consent is the legal basis for informed consent. Under which of the following is this doctrine usually outlined?
    A. Local government regulations
    B. Facility policy
    C. State medical practice acts
    D. Federal statutes

 

  1. Which of the following information is not usually included in the process of the doctrine of informed consent?
    A. Proposed modes of treatment
    B. Risks involved in the procedure
    C. Available alternative modes of treatment
    D. The reputation of the physician performing the procedure

 

  1. Which of the following is an example of a patient who usually cannot give informed consent?
    A. An emancipated minor
    B. A married minor
    C. A mature minor
    D. An adult who is mentally incompetent

 

  1. Which of the following aspects of patient care is the most vital factor to the issue of informed consent?
    A. Patient care
    B. Patient education
    C. Patient compliance
    D. Patient maturity

 

  1. Which of the following cases legalized abortion at the Supreme Court level?
    A. Jones v. Davis
    B. Roe v. Davis
    C. Roe v. Wade
    D. Jones v. Wade

 

 

  1. In Planned Parenthood v. Casey, 505 U.S. 833 (1992) which of the following provisions was the only provision to fail the “undue burden” test?
    A. The husband notification requirement
    B. The parental consent for a minor
    C. A 48-hour waiting period prior to the procedure
    D. Informed consent of the pregnant woman following a 24-hr waiting period

 

  1. Technically, abortion is legal in how many states?
    A. 25
    B. 30
    C. 40
    D. 50

 

  1. State public health law varies for human immunodeficiency virus (HIV) testing, but, generally, health care practitioners must consider which of the following guidelines when providing this type of testing?
    A. Children who contract HIV may make informed decisions in their health care.
    B. Married minors do not have the right to give consent for HIV testing.
    C. Generally, parental consent is required for a physician to treat a minor with HIV.
    D. Guardians must consent to treatment for HIV for emancipated minors.

 

  1. In which of the following situations is a physician not expected to obtain consent before proceeding with treatment?
    A. When a parent or legal guardian is present for a minor.
    B. When the physician is acting in an emergency situation.
    C. When an emancipated minor is seeking testing for HIV/AIDS.
    D. When a patient is mentally incompetent or unconscious.

 

  1. The Good Samaritan Acts were passed to protect physicians from being charged with which of the following torts?
    A. Invasion of privacy
    B. Assault
    C. Battery
    D. Negligence

 

 

  1. A physician stops to aid the driver of a truck that overturned on the side of the road. Which of the following actions may negate the immunity that would otherwise be provided by the Good Samaritan Acts?
    A. Billing for services
    B. Providing care in good faith
    C. Using due care under the circumstances
    D. Acting within the scope of training

 

  1. Which of the following statements is true regarding the provisions of the Good Samaritan Acts?
    A. They protect physicians who are employed to work in an emergency department.
    B. The person giving aid owes the stranger a duty of being reasonably careful.
    C. A person who is qualified to do first aid is obligated to do so in most states.
    D. The person’s consent is not required in emergency situations.

 

  1. Which of the following is a central component of health information technology (HIT)?
    A. The patient’s medical file
    B. Informed consent
    C. Good Samaritan Acts
    D. Negligence

 

  1. What was the goal of the Patient Protection and Affordable Care Act signed into law in 2010?
    A. Ensuring patient confidentiality
    B. Providing protection for health care practitioners who give first aid
    C. Lowering the cost of liability insurance premium
    D. Converting patient records to an electronic format

 

 

  1. Which of the following legislation addresses privacy of health information and mandates certain procedures and standards for the electronic transmission and storage of health care information?
    A. Health Insurance Portability and Accountability Act (HIPAA)
    B. Patient Protection and Affordable Care Act
    C. Health Information Standards Developed by Health and Human Services (HHS)
    D. Establishment of a National Coordinator for Health Information Technology.

 

  1. Which of the following legislation created standards for transmitting X-rays, laboratory results, and prescriptions over the Internet?
    A. Health Insurance Portability and Accountability Act (HIPAA)
    B. Patient Protection and Affordable Care Act
    C. Health Information Standards Developed by Health and Human Services (HHS)
    D. Establishment of a National Coordinator for Health Information Technology.

 

  1. Which of the following is a result of the promotion of health information technology (HIT) in the medical industry?
    A. Decreased administrative efficiency
    B. Expanded access to affordable care
    C. Increased paperwork
    D. Increased medical errors

 

  1. Which of the following is a public health benefit that will occur with expanded use of health information technology (HIT) in the medical industry?
    A. Early detection of infectious outbreaks around the country
    B. Reduction of health care costs
    C. Decreased paperwork
    D. Prevention of medical errors

 

 

  1. According to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, as quoted in the July 13, 2010, issue of the New York Times, what percent of doctors use even the most basic electronic records?
    A. 10
    B. 20
    C. 30
    D. 40

 

  1. Alicia’s computer monitor is easily viewed by patients as they are sitting at her station. She notices that a patient is making an intent effort to read the information on the computer screen. That information concerns another patient that Alicia had just talked with. What should Alicia do?
    A. Distract the patient from looking at the monitor.
    B. Ignore the patient’s attempt to view the monitor.
    C. Fix the computer so no information is on the screen.
    D. Put a chart in front of the screen.

 

 

Fill in the Blank Questions

  1. A ____________________ is a collection of data recorded when a patient seeks medical treatment.
    ________________________________________

 

  1. Patient medical records serve as _________________________in lawsuits.
    ________________________________________

 

  1. The five Cs that describe the necessary attributes of entries to patients’ medical records are: concise, complete, clear, correct, and __________________________.
    ________________________________________

 

 

  1. A physician who photographs a patient’s image without obtaining proper consent may be vulnerable to the charge of __________________________in a court of law.
    ________________________________________

 

  1. A physician employed by a hospital, obtains consent to photograph a patient’s pressure wound for comparison after treatment. The physician must make sure the patient understands ownership of the rights of the images will be retained by the _________________________.
    ________________________________________

 

  1. Images of a patient who was cured of cancer are being used for publicity for the medical facility. If the images will be used for___________________ or publicity purposes, a separate consent form should be used.
    ________________________________________

 

  1. A nurse makes an error while documenting the vital signs of a patient on the medical record. When correcting the error, the nurse should _____________________________ through the error so that it is still legible, and write or type in the correct above or below the original line or in the margin.
    ________________________________________

 

  1. The nurse writes the date in a medical record as 9/6 when she meant to write 9/7. The nurse should write ________________near the correction to state why the error was made.
    ________________________________________

 

  1. Patients’ medical records are considered the property of the ­­­­­­­­_______________ of the facility where they were created.
    ________________________________________

 

 

  1. A medical facility generates hundreds of patient medical records during the course of patient treatment. The medical facility owns the documents, and the _________________
    owns the information they contain.
    ________________________________________

 

  1. A physician decides that a patient with a mental condition may be harmed by seeing his own medical record. This decision may hold up in court under the doctrine of __________________________________.
    ________________________________________

 

  1. Under the legislation known as _________________________________________, patients who ask to see and/or copy their medical records must be accommodated, with a few exceptions.
    ________________________________________

 

  1. A potential employer schedules and pays for a physical for a job candidate prior to hiring her. When this occurs, the ________________________owns the medical record.
    ________________________________________

 

  1. As a protection in the event of litigation, records should be kept until the applicable ____________________________ period has elapsed, which generally ranges from two to seven years.
    ________________________________________

 

  1. Since medical office personnel have a duty to protect the privacy of the patient, medical records should not be released to a third party without written ___________________, signed by the patient or the patient’s legal representative.
    ________________________________________

 

 

  1. When medical records are requested for use in a lawsuit, a _____________________ for the release of the records must be obtained from the patient, unless a court subpoenas the records.
    ________________________________________

 

  1. A physician is obliged to his patient based on trust and confidence to follow the procedure to protect against unauthorized release of patient medical information. This is known as a ______________________________.
    ________________________________________

 

  1. A federal statute that protects patients with histories of substance abuse regarding the release of information about treatment is known as ______________________________
    __________________.
    ________________________________________

 

  1. A patient gives permission for a physician to treat his hypertension. The permission is called ____________________.
    ________________________________________

 

  1. A patient makes an appointment with a nurse practitioner for a pap test. This is an example of ___________________consent.
    ________________________________________

 

  1. A patient is undergoing a surgical procedure to remove the foot of a patient with diabetes. The consent for this procedure is called _________________consent.
    ________________________________________

 

  1. The doctrine of informed consent is the legal basis for informed consent, usually outlined in a state’s __________________________________.
    ________________________________________

 

 

  1. A 17-year old is living alone and responsible for his own support. When hospitalized following a motorcycle accident, it is determined that the minor has been through court to be declared _______________________and can consent to his own health care treatment.
    ________________________________________

 

  1. Those minors who have been granted the right to seek birth control or care during pregnancy, treatment for reportable communicable diseases, or treatment for drug-or alcohol-related problems without first obtaining parental consent are called _____________________minors.
    ________________________________________

 

  1. A hospitalized patient does not speak or understand English, and needs surgery to prevent a brain hemorrhage. A(n) ___________________ may be necessary to inform the patient and obtain his or her consent for treatment.
    ________________________________________

 

  1. In the law case ___________________________________, the U.S. Supreme Court upheld a 24-hour waiting period, an informed consent requirement, a parental consent provision for minors, and a record-keeping requirement for women seeking an abortion.
    ________________________________________

 

  1. _____________________________is the 1973 Supreme Court decision that legalized abortion in the United States.
    ________________________________________

 

  1. A nurse helps a pedestrian who is struck by a car when crossing the street. In an emergency situation such as this, the nurse is not expected to obtain ________________ before proceeding with treatment.
    ________________________________________

 

 

  1. ________________________Acts were intended to protect physicians and, in some states, other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help the victim of an accident or other emergency.
    ________________________________________

 

  1. Medical records were destroyed in a fire in a medical facility. This facility could have prevented the hardships that occurred due to the loss of medical records by using ________________medical records.
    ________________________________________

 

  1. Under the ­­­­­­­­___________________________Act signed into law in 2010, physicians could receive up to $44,000 from the government to help with the cost of converting to electronic health records.
    ________________________________________

 

  1. A health care facility protects the privacy of patients by following facility policy for the electronic transmission and storage of health care information. These policies are mandated by the _____________________________________Act, passed in l996.
    ________________________________________

 

  1. In April 2004, President George W. Bush signed an executive order establishing the position of ________________________________________________ to oversee a plan for nationwide adoption of health information technology.
    ________________________________________

 

  1. An x-ray technician transmits a patient’s x-rays over the Internet to be interpreted by the patient’s physician. The adoption of the __________________________________
    developed by Health and Human Services (HHS) has set standards for electronically transmitting this type of information as well as transmitting lab results and prescriptions electronically.
    ________________________________________

 

 

  1. As one of the largest buyers of health care in Medicare, Medicaid, the Community Health Centers program, the Federal Health Benefits program, veterans’ medical care, and programs in the Department of Defense, the ____________________ can create incentives and opportunities for health care providers to use electronic records.
    ________________________________________

 

  1. One public health benefit of using health information technology is the early detection of _______________________outbreaks around the country.
    ________________________________________

 

  1. While the goal of widespread adoption of electronic health records by 2014 seems beneficial, many physicians and hospitals have not been eager to digitalize written records because the process is ________________________ and often fraught with information technology headaches.
    ________________________________________

 

  1. According to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, as quoted in the July 13, 2010, issue of the New York Times, just­­­_____ percent of doctors and 10 percent of hospitals use even the most basic electronic records.
    ________________________________________

 

  1. Health care providers who treat ___________________patients must convert patient records to electronic health records (EHRs) by 2015 or face lower fee reimbursements from the federal government.
    ________________________________________

 

  1. In order to protect patient information, discarded copies of confidential information should be ______________________.
    ________________________________________

 

 

  1. When using the computer to access patient information, health care professionals should place the _____________________in an area where no one will see it.
    ________________________________________

 

  1. Since medical records are ______________________, and law protects their confidentiality, health care practitioners must take every precaution to properly enter information into medical records and to keep that information confidential.
    ________________________________________

 

 

Short Answer Questions

  1. An attorney subpoenas a patient’s medical record in a malpractice lawsuit. The legal term for this action is ____________________________.

 

 

 

 

  1. An attorney issues a ____________________________for a witness to appear in court and bring certain medical records.

 

 

 

 

 

 

 

 

 

Multiple Choice Questions

  1. A nurse carefully documents all pertinent patient information in the patient medical record. Which of the following is true of this document?
    A.Medical records are voluntary and are not required by licensing authorities.
    B. Medical records provide documentation of a patient’s health care from birth to death.
    C. Medical records do not serve as legal documents in lawsuits.
    D. Medical records can be changed as a patient’s condition improves or worsens.

Medical records provide documentation of a patient’s continuing health care, from birth to death. Medical records are required by licensing authorities and provide a format for tracking, documenting, and maintaining a patient’s communication data, both inside and outside a health care facility. They provide a foundation for managing a patient’s health care, and serve as legal documents in lawsuits. Medical records can be updated as new data is added, but not changed.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. A subpoena duces tecum is ordered during a malpractice trial. What does this subpoena provide as evidence?
    A.Expert witness testimony
    B. Fact witnesses
    C. Medical records
    D. Telephone transcripts

As a legal document, a patient’s medical record may be subpoenaed (via subpoena duces tecum) as evidence in court.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. Medical records are often subpoenaed for court trials. Which of the following is true regarding the use of medical records as evidence?
    A.If there is no entry in the medical record it cannot be presumed that it was not done.
    B. Records for legal purposes must be kept on paper.
    C. Medical records do not prevail over a patient’s recollection of events during a trial.
    D. What is omitted from the record may be as important to the trial as what is included.

When there is no entry in the record to the effect that something was done, there is a presumption that it was not done, and when there is an entry that something was done, the presumption is that it was done. Therefore, what is omitted from the record may be as important to the outcome of a lawsuit as what is included. Records may be kept on paper, microfilm, or computer tapes or disks. When they are conscientiously compiled, medical records can prevail over a patient’s recollection of events during a trial.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. The Five Cs are used to describe the attributes of entries in a patient’s medical record. Which of the following is not one of the 4Cs?
    A.Concise
    B. Complete
    C. Chronologically ordered
    D. Clean

The 5 Cs of charting are: (1) concise, (2) complete (and objective), (3) clear (and legibly written), (4) correct, and (5) chronologically ordered.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. Which of the following should not be included in a patient’s medical record?
    A.Personal judgments
    B. Times of arrival for appointments
    C. Social security number
    D. Driver’s license information

Medical records should never include inappropriate personal judgments or observations or attempts at humor.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. A plastic surgeon documents the before and after pictures of a patient after receiving a signed consent from the patient. Which of the following torts might occur from photographing a patient without proper consent?
    A.Assault
    B. Defamation
    C. Invasion of privacy
    D. Negligence

Photographing or otherwise recording a patient’s image without proper consent may be interpreted in a court of law as invasion of privacy. Invasion of privacy charges are most often upheld in court if the patient’s image was used for commercial purposes, but such claims have also been upheld under public disclosure of embarrassing private facts. For example, “before” and “after” photographs published by a cosmetic surgeon may cause embarrassment to the patient if he or she did not give consent for the photographs to be published.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. A plastic surgeon routinely photographs patients to document care. Which of the following accurately describes information that should be included on the consent form for this type of photography?
    A.The patient understands that ownership rights to the photos belong to the patient.
    B. The patient understands that the photos will be kept for an undetermined time period.
    C. The patient understands that he or she cannot view the photographs.
    D. The patient understands that authorization must be given to release photos outside the facility.

If a health care facility routinely photographs patients to document care, a special consent form should be signed stating that: (1) The patient understands that photographs, videotapes, and digital or other images may be taken to document care; (2) The patient understands that ownership rights to the images will be retained by the health care facility, but that he or she will be allowed to view them or to obtain copies; (3) The images will be securely stored and kept for the time period prescribed by law or outlined in the health care facility’s policy; and (4) Images of the patient will not be released and/or used outside the health care facility without written authorization from the patient or his or her legal representative.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. Under which of the following circumstances should a separate consent form be obtained to use patient images?
    A.When they will be used for teaching purposes.
    B. When they will be used to document routine care.
    C. When they will be used to document a new procedure.
    D. When they will be used to document before and after patient conditions.

If patient images will be used for teaching or publicity, a separate consent form should be obtained from the patient.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. A nurse documenting patient care makes an error when recording the vital signs. Which of the following is the correct guideline for correcting errors in a patient’s medical record?
    A.Black out the information with a permanent magic marker and write above the entry.
    B. Draw a line through the error so that it is still legible and write above or below the line.
    C. Use correction fluid to white out the error and write the entry on top of the white-out.
    D. Do not place the correction on a separate piece of paper, rather write in the margins of the original copy.

Guidelines when correcting errors in a client’s medical record include: Draw a line through the error so that it is still legible; Do not black out the information or use correction fluid to cover it up and write or type in the correct information above or below the original line or in the margin; If necessary, attach another sheet of paper or another document with the correction on it – In this case, note in the record “See attached document A” to indicate where the corrected information can be found.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. A physician is documenting patient information on the medical record and receives a phone call that distracts him, causing him to record the wrong medication prescription. Which of the following is a correct guideline for correcting the medical record error?
    A.Do not make a change in the record without noting the reason for it.
    B. Enter the date and time and have the patient initial the correction.
    C. Ask two other staff members to initial the correction to the record.
    D. Put all corrections on a separate piece of paper and attach to the back of the record

The physician should note near the correction why it was made (for example, “error, wrong date,” or “error, interrupted by a phone call”), and place this note in the margin or, again, add an attachment. A change in the record should not be made without noting the reason for it. The physician should also enter the date and time, and initial the correction, and if possible, ask another staff member to witness and initial the correction to the record when it is made. Corrections may be made above or below the correction or in the margins, or on a separate piece of paper that is marked “see attached document.”

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. A physician has a private practice employing a physician assistant and two nurses. The physician also has hospital privileges at a nearby facility. Who owns the medical records generated by his office?
    A.The patient
    B. The hospital
    C. The nurses
    D. The physician

Patients’ medical records are considered the property of the owners of the facility where they were created. For example, a physician in private practice owns his or her records; records in a clinic are the property of the clinic. Hospital records are the property of the admitting hospital.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

  1. A hospital maintains medical records on all patients who are treated. Who owns the information contained in the medical record?
    A.The patient
    B. The treating physician
    C. The hospital
    D. The nurse

The facility where the medical records were created owns the documents, but the patient owns the information they contain.On signing a release, patients may usually obtain access to or copies of their medical records, depending on state law.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

 

 

  1. The doctrine of professional discretion pertains to medical record keeping. Which of the following does this doctrine occasionally uphold in court?
    A.Patients should be able to obtain access to or copies of their medical records according to state law.
    B. It is up to the discretion of the physician whether or not to allow all patients access to their medical records.
    C. In cases where viewing the medical record may cause harm to patients, it is up to the health care provider whether or not to allow them access to the medical record.
    D. It is up to the discretion of the facility whether or not to allow patients access to their medical records.

On signing a release, patients may usually obtain access to or copies of their medical records, depending on state law. However, under the doctrine of professional discretion, courts have held that in some cases, seeing their own records may harm patients treated for mental or emotional conditions.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

  1. Which of the following legislation states that patients that ask to see and/or copy their medical records must be accommodated with a few exceptions?
    A.FDA
    B. JACHO
    C. HIPAA
    D. OSHA

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law providing privacy and other health care rights of patients, including seeing or copying their medical record. The FDA (Federal Drug Administration) works to ensure safe medications. The Joint Commission (JACHO) is involved in licensing and credentialing of health care facilities. OSHA (Occupational Safety and Health Administration) deals with safety in the workplace.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

 

 

  1. A physician in a private practice examines a patient who is being considered for a job with a pharmaceutical company. The prospective employer pays for the physical. Who is the owner of the medical record in this example?
    A.The patient
    B. The physician
    C. The prospective employer
    D. The government

When a physician in private practice examines a patient for a job-related physical, scheduled and paid for by the patient’s employer or prospective employer, those records are still the physician’s property, but the employer is entitled to a copy of the record that is pertinent to the job-related exam.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

  1. As a protection in the event of litigation, records should be kept until the applicable statute of limitations period has elapsed. What is the usual timeframe for this period of time?
    A.1 to 5 years
    B. 2 to 7 years
    C. 5 to 10 years
    D. 12 to 20 years

As a protection in the event of litigation, records should be kept until the applicable statute of limitations period has elapsed, which generally ranges from two to seven years. In some cases, this involves keeping the medical records for minor patients for a specified length of time after they reach legal age.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

 

 

  1. Which of the following describes the proper protocol for the release of medical records?
    A.Medical records may be released to third party payers without patient consent.
    B. When patient information is requested the entire medical record should be released.
    C. Signed consent for medical records is not required for use in a lawsuit.
    D. When medical records are subpoenaed, the patient should be notified in writing.

Medical records should not be released to a third party without written permission, signed by the patient or the patient’s legal representative. Only the information requested should be released. When medical records are requested for use in a lawsuit, a signed consent for the release of the records must be obtained from the patient, unless a court subpoenas the records. In this case, the patient should be notified in writing that the records have been subpoenaed and released.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. Which of the following occurs with the medical record when a patient transfers to another physician?
    A.The original medical record is sent to the new physician.
    B. The patient signs an authorization to release his or her records to the new physician.
    C. A new medical record is started that does not contain the old record information.
    D. The old medical record is destroyed.

When a patient transfers to another physician, the physician may photocopy and send all records, or may send a summary. The patient must sign an authorization to release records.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. In which of the following cases would patient authorization for release of his or her medical record be waived?
    A.For an insurance claim
    B. When transferring to another physician
    C. When a subpoena duces tecum is issued
    D. When a patient dies

When a subpoena duces tecum is issued for certain records (the subpoena commands a witness to appear in court and to bring certain medical records), the patient’s written consent to release the records is waived.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. A physician has an obligation to his or her patient based on trust and confidence. What is the term for this obligation?
    A.Fiduciary duty
    B. Breach of confidence
    C. Consent
    D. Caring relationship

A fiduciary duty is a physician’s obligation to his or her patient, based on trust and confidence. Breach of confidence occurs when health care providers do not protect patient information. Individuals responsible for releasing medical information must follow procedure to protect against unauthorized release of patient medical records. By givingconsent, the patient gives permission, either expressed (orally or in writing) or implied, for the physician to examine him or her, to perform tests that aid in diagnosis, and/or to treat for a medical condition. A caring relationship is beneficial to the patient, but is not the fiduciary duty of the physician.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A physician receives a subpoena for a patient’s medical records to help determine an award in a workmen’s compensation case. How would the physician handle this request?
    A.Send the entire original medical record to the court.
    B. Photocopy the medical record and send it to the plaintiff.
    C. Photocopy the medical record and send to the attorney who issued the subpoena.
    D. Send a release of information form to the patient to sign for release of the records.

Physicians receive subpoenas for patient medical records for a variety of reasons including: accidents involving patients, workers’ compensation claims, and other non-medical-liability reasons. When this occurs, the medical office sends a photocopy of the patient’s medical records to the attorney who issued the subpoena.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. When a physician is sued for malpractice, whom might the responsibility to comply with a subpoena to produce medical records fall?
    A.The nurse
    B. The physician
    C. The patient
    D. The medical office employee

When a physician is sued for medical malpractice, responsibility to comply with a subpoena to produce specified medical records in court may fall to the medical office employee in charge of medical records.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A subpoena duces tecum is issued for the medical records of a patient who is suing the physician for malpractice. Which of the following is a guideline for sending this information?
    A.Verify that the patient named was not a patient of the physician.
    B. Notify the insurance company officials and have them notify the physician.
    C. Finish or change any subpoenaed records that are not complete or up to date.
    D. Offer sworn testimony regarding the record if instructed to do so by the court.

The person in charge of records should offer sworn testimony regarding the record, if so instructed by the court; verify that the patient named was a patient of the physician named; notify the physician that a subpoena was received; and then notify the physician’s insurance company or attorney, if so directed, and check all subpoenaed records to be sure they are complete, but never alter them in any way.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. When a patient medical record is subpoenaed by the court, which of the following information must be listed on the subpoena?
    A.The name and phone number of the judge
    B. The trial date and time
    C. The physician’s license number
    D. The formal complaint of the patient

The subpoena should contain the name and phone number of the issuing attorney, the court docket number of the case, the trial date and time, the name of the patient and the medical records requested.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Which of the following information is the federal statute known as the Confidentiality of Alcohol and Drug Abuse, Patient Records designed to protect?
    A.Patient treatment
    B. Patient convictions
    C. Patient behavior
    D. Physician liability

The federal statute: Confidentiality of Alcohol and Drug Abuse, Patient Records protects patients with histories of substance abuse regarding the release of information about treatment. Under no circumstances should information of this type be released without specific, written permission from the patient to do so.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. The person in charge of medical records for a physician’s office is preparing to release medical records requested by an insurance company. Which of the following is a recommended guideline for this procedure?
    A.Receive a verbal authorization from the patient prior to releasing the patient record.
    B. Verify the patient’s name, address, and date of birth on the authorization.
    C. Release the entire record, not just the information specifically requested.
    D. Warn patient that once authorized, consent to release information cannot be rescinded.

Guidelines for authorization for releasing patient information include: (1) Authorizations should be in writing; (2) Authorizations should include the patient’s name, address, and date of birth; (3) The patient should sign authorizations, unless he or she is not a legal, competent adult – In that case, parents or guardians should sign authorizations; (4) Only the information specifically requested should be released; and (5) The patient has the right to rescind a consent to release information, in which case information should not be released.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Which of the following is not a requirement when a request for information comes into the medical office from insurance companies, physicians, or other sources?
    A.It must be witnessed and dated.
    B. It must include the name, address, and signature of the party releasing information.
    C. It must list the purpose for which the data will be used.
    D. It must state that the information will not be used in court trial

Requests for information coming into the medical office from insurance companies, physicians, or other sources should be witnessed and dated and include the complete name, address, and signature of the party requesting the information, as well as that of the party asked to release the information. It should also include a specific description of the information that is needed, the purpose for which the data will be used, and the date on which the consent expires.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. What is the legal term for the permission a patient gives for a physician to examine him or her, to perform tests, and/or treat a medical condition?
    A.Fiduciary duty
    B. Confidentiality
    C. Consent
    D. Authorization

By givingconsent, the patient gives permission, either expressed (orally or in writing) or implied, for the physician to examine him or her, to perform tests that aid in diagnosis, and/or to treat for a medical condition.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Which of the following is an example of implied consent?
    A.A patient makes an appointment for an examination.
    B. A patient signs an informed consent for surgery.
    C. A patient states that he or she will cooperate with diagnostic testing.
    D. A patient states that he or she will take medications prescribed.

By givingconsent, the patient gives permission, either expressed (orally or in writing) or implied, for the physician to examine him or her, to perform tests that aid in diagnosis, and/or to treat for a medical condition. When the patient makes an appointment for an examination, that patient has given implied consent for the physician to perform the exam. The other examples are expressed consent.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. For which of the following examples would implied consent not be legally appropriate?
    A.A physician treats a patient for prostate cancer.
    B. A patient provides a urine specimen to check for UTI.
    C. A patient agrees to a test for HIV.
    D. A patient has his blood pressure taken during an examination.

By givingconsent, the patient gives permission, either expressed (orally or in writing) or implied, for the physician to examine him or her, to perform tests that aid in diagnosis, and/or to treat for a medical condition. When the patient makes an appointment for an examination, that patient has given implied consent for the physician to perform the exam. Likewise, when he or she cooperates with various diagnostic testing procedures, implied consent for the tests has been given.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. The doctrine of informed consent is the legal basis for informed consent. Under which of the following is this doctrine usually outlined?
    A.Local government regulations
    B. Facility policy
    C. State medical practice acts
    D. Federal statutes

Informed consent involves the patient’s right to receive all information relative to his or her condition and then to make a decision regarding treatment based on that knowledge. The legal basis for informed consent is usually outlined in a state’s medical practice acts.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. Which of the following information is not usually included in the process of the doctrine of informed consent?
    A.Proposed modes of treatment
    B. Risks involved in the procedure
    C. Available alternative modes of treatment
    D. The reputation of the physician performing the procedure

Informed consent implies that the patient understands the following: proposed modes of treatment, why the treatment is necessary, risks involved in the proposed treatment, available alternative modes of treatment, risks of alternative modes of treatment, and risks involved if treatment is refused.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Which of the following is an example of a patient who usually cannot give informed consent?
    A.An emancipated minor
    B. A married minor
    C. A mature minor
    D. An adult who is mentally incompetent

Individuals judged by the court to be insane, senile, mentally challenged, or under the influence of drugs or alcohol cannot give informed consent. In these cases, a competent person may be designated by the court to act as the patient’s agent. Minors cannot generally give informed consent unless they are emancipated, married, or mature minors.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. Which of the following aspects of patient care is the most vital factor to the issue of informed consent?
    A.Patient care
    B. Patient education
    C. Patient compliance
    D. Patient maturity

Patient education is vital to the issue of informed consent. Patients who sue have successfully claimed lack of informed consent because they did not read the consent form they signed or did not read brochures handed to them. Health care personnel should be sure that patients understand all forms and all treatments/surgeries to be performed before signing.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Which of the following cases legalized abortion at the Supreme Court level?
    A.Jones v. Davis
    B. Roe v. Davis
    C. Roe v. Wade
    D. Jones v. Wade

The Court in Roe v. Wade held that the constitutional right to privacy includes a woman’s decision to terminate a pregnancy during the first trimester (three months), but that states could impose restrictions and regulate abortions after that.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. In Planned Parenthood v. Casey, 505 U.S. 833 (1992) which of the following provisions was the only provision to fail the “undue burden” test?
    A.The husband notification requirement
    B. The parental consent for a minor
    C. A 48-hour waiting period prior to the procedure
    D. Informed consent of the pregnant woman following a 24-hr waiting period

The Pennsylvania legislature amended its abortion control law in 1988 and 1989. Among the new provisions, the law required informed consent and a 24-hour waiting period prior to the procedure. A minor seeking an abortion required the consent of one parent (the law allowed for a judicial bypass procedure). A married woman seeking an abortion had to indicate that she notified her husband of her intention to abort the fetus. Several abortion clinics and physicians challenged these provisions. A federal appeals court upheld all the provisions except the husband notification requirement.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Technically, abortion is legal in how many states?
    A.25
    B. 30
    C. 40
    D. 50

Technically, abortion is legal in all 50 states, but state legislatures have added restrictions.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. State public health law varies for human immunodeficiency virus (HIV) testing, but, generally, health care practitioners must consider which of the following guidelines when providing this type of testing?
    A.Children who contract HIV may make informed decisions in their health care.
    B. Married minors do not have the right to give consent for HIV testing.
    C. Generally, parental consent is required for a physician to treat a minor with HIV.
    D. Guardians must consent to treatment for HIV for emancipated minors.

Infants and young children do not have the capacity to consent because they do not yet have the ability to make informed decisions. The person legally designated to make health care decisions for the child has the right to decide whether the child should be tested for HIV. Married minors, emancipated minors, and minor parents may have the right to give consent for HIV testing, depending on state law.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. In which of the following situations is a physician not expected to obtain consent before proceeding with treatment?
    A.When a parent or legal guardian is present for a minor.
    B. When the physician is acting in an emergency situation.
    C. When an emancipated minor is seeking testing for HIV/AIDS.
    D. When a patient is mentally incompetent or unconscious.

In emergency situations, when the patient is in immediate danger, the physician is not expected to obtain consent before proceeding with treatment. In the other examples, informed consent must still be obtained from the patient or from the patient’s parent or legal guardian, or authorized family members.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. The Good Samaritan Acts were passed to protect physicians from being charged with which of the following torts?
    A.Invasion of privacy
    B. Assault
    C. Battery
    D. Negligence

All 50 states have passed Good Samaritan Acts. These acts were intended to protect physicians and, in some states, other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help the victim of an accident or other emergency.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A physician stops to aid the driver of a truck that overturned on the side of the road. Which of the following actions may negate the immunity that would otherwise be provided by the Good Samaritan Acts?
    A.Billing for services
    B. Providing care in good faith
    C. Using due care under the circumstances
    D. Acting within the scope of training

If a physician treats a patient as a “Good Samaritan” and later bills the patient for services, he or she may be held as having established a physician–patient relationship and may not have the immunity from civil damages that a Good Samaritan law would otherwise provide.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. Which of the following statements is true regarding the provisions of the Good Samaritan Acts?
    A.They protect physicians who are employed to work in an emergency department.
    B. The person giving aid owes the stranger a duty of being reasonably careful.
    C. A person who is qualified to do first aid is obligated to do so in most states.
    D. The person’s consent is not required in emergency situations.

Good Samaritan in legal terms refers to someone who renders aid in an emergency to an injured person on a voluntary basis. Usually, if a volunteer comes to the aid of an injured or ill person who is a stranger, the person giving the aid owes the stranger a duty of being reasonably careful. A person is not obligated by law to do first aid in most states, unless it’s part of a job description (such as an emergency department doctor). HoweverRemember,me states will consider it an act of negligence if a person doesn’t at least call for help. Generally, where an unconscious victim cannot respond, a Good Samaritan can help on the grounds of implied consent. However, if the victim is conscious and can respond, a person should first ask permission to help.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Which of the following is a central component of health information technology (HIT)?
    A.The patient’s medical file
    B. Informed consent
    C. Good Samaritan Acts
    D. Negligence

A central component of HIT is the patient’s medical file, and as electronic medical records become more widely adopted, confidentiality and privacy concerns must be addressed. Consent is permission from a person, either expressed or implied, for something to be done by another. Good Samaritan Acts are state laws protecting physicians and sometimes other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help the victim of an accident or other emergency. Negligence is an unintentional act that causes harm to another person.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. What was the goal of the Patient Protection and Affordable Care Act signed into law in 2010?
    A.Ensuring patient confidentiality
    B. Providing protection for health care practitioners who give first aid
    C. Lowering the cost of liability insurance premium
    D. Converting patient records to an electronic format

As of 2004, President George W. Bush had set a 10-year goal for the broad adoption of electronic health records in the United States. President Barack Obama, who took office January 1, 2009, continued to urge health care providers to convert records to electronic form. Under the Patient Protection and Affordable Care Act signed into law in 2010, physicians could receive up to $44,000 from the government to help with the cost of converting to electronic health records.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. Which of the following legislation addresses privacy of health information and mandates certain procedures and standards for the electronic transmission and storage of health care information?
    A.Health Insurance Portability and Accountability Act (HIPAA)
    B. Patient Protection and Affordable Care Act
    C. Health Information Standards Developed by Health and Human Services (HHS)
    D. Establishment of a National Coordinator for Health Information Technology.

HIPAA addresses privacy of health information and mandates certain procedures and standards for the electronic transmission and storage of health care information. Under the Patient Protection and Affordable Care Act signed into law in 2010, physicians could receive up to $44,000 from the government to help with the cost of converting to electronic health records. HHS has negotiated and licensed a comprehensive medical vocabulary and made it available to everyone in the United States at no cost. In April 2004, President George W. Bush signed an executive order establishing the position of National Coordinator for Health Information Technology. The coordinator was charged with the development, maintenance, and oversight of a plan for nationwide adoption of health information technology.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. Which of the following legislation created standards for transmitting X-rays, laboratory results, and prescriptions over the Internet?
    A.Health Insurance Portability and Accountability Act (HIPAA)
    B. Patient Protection and Affordable Care Act
    C. Health Information Standards Developed by Health and Human Services (HHS)
    D. Establishment of a National Coordinator for Health Information Technology.

The results of HSS projects include standards for the following types of information: transmitting X-Rays, lab results, and prescriptions over the Internet. HIPAA addresses privacy of health information and mandates certain procedures and standards for the electronic transmission and storage of health care information. Under the Patient Protection and Affordable Care Act signed into law in 2010, physicians could receive up to $44,000 from the government to help with the cost of converting to electronic health records. The national coordinator was charged with the development, maintenance, and oversight of a plan for nationwide adoption of health information technology.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. Which of the following is a result of the promotion of health information technology (HIT) in the medical industry?
    A.Decreased administrative efficiency
    B. Expanded access to affordable care
    C. Increased paperwork
    D. Increased medical errors

The federal government maintains that the broad use of health information technology will improve individual patient care by: improving health care quality, preventing medical errors, reducing health care costs, increasing administrative efficiency, decreasing paperwork, and expanding access to affordable care.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. Which of the following is a public health benefit that will occur with expanded use of health information technology (HIT) in the medical industry?
    A.Early detection of infectious outbreaks around the country
    B. Reduction of health care costs
    C. Decreased paperwork
    D. Prevention of medical errors

HIT will improve public health by detecting infectious outbreaks sooner, improving tracking of chronic disease management, and evaluation of health care based on comparisons of price and quality. Patient care will be improved by reduction of health care costs, decreased paperwork, and prevention of medical errors.

 

Bloom’s: Analyzing
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. According to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, as quoted in the July 13, 2010, issue of the New York Times, what percent of doctors use even the most basic electronic records?
    A.10
    B. 20
    C. 30
    D. 40

According to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, as quoted in the July 13, 2010, issue of the New York Times, just 20 percent of doctors and 10 percent of hospitals use even the most basic electronic records. Under federal legislation passed in 2009, the Department of Health and Human Services set aside $27 billion to help health care providers convert patients’ records to electronic health records (EHRs).

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. Alicia’s computer monitor is easily viewed by patients as they are sitting at her station. She notices that a patient is making an intent effort to read the information on the computer screen. That information concerns another patient that Alicia had just talked with. What should Alicia do?
    A.Distract the patient from looking at the monitor.
    B. Ignore the patient’s attempt to view the monitor.
    C. Fix the computer so no information is on the screen.
    D. Put a chart in front of the screen.

Alicia should immediately fix the screen so confidential information is not displayed. She should also remember to do this routinely so it doesn’t happen again.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

Fill in the Blank Questions

  1. A ____________________ is a collection of data recorded when a patient seeks medical treatment.
    Medical record

A medical record is a collection of data recorded when a patient seeks medical treatment. Hospitals, surgical centers, clinics, physician offices, and other facilities providing health care services maintain patients’ medical records.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. Patient medical records serve as _________________________in lawsuits.
    Legal documents

Medical records serve many purposes including serving as legal documents in malpractice lawsuits.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. The five Cs that describe the necessary attributes of entries to patients’ medical records are: concise, complete, clear, correct, and __________________________.
    Chronologically ordered

Entries in a patient record must be concise, complete and objective, clear and legibly written, correct, and chronologically ordered. They should never contain inappropriate judgments or observations or attempts at humor.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. A physician who photographs a patient’s image without obtaining proper consent may be vulnerable to the charge of __________________________in a court of law.
    Invasion of privacy

Photographing or otherwise recording a patient’s image without proper consent may be interpreted in a court of law as invasion of privacy. Invasion of privacy charges are most often upheld in court if the patient’s image was used for commercial purposes, but such claims have also been upheld under public disclosure of embarrassing private facts.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. A physician employed by a hospital, obtains consent to photograph a patient’s pressure wound for comparison after treatment. The physician must make sure the patient understands ownership of the rights of the images will be retained by the _________________________.
    Hospital

The patient should understand that photographs, videotapes, and digital or other images might be taken to document care. The patient should know that ownership rights to the images will be retained by the hospital, but that he or she will be allowed to view them or to obtain copies.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. Images of a patient who was cured of cancer are being used for publicity for the medical facility. If the images will be used for___________________ or publicity purposes, a separate consent form should be used.
    Teaching

Images of the patient will not be released and/or used outside the health care facility without written authorization from the patient or his or her legal representative. If patient images will be used for teaching or publicity purposes, a separate consent form should be used.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. A nurse makes an error while documenting the vital signs of a patient on the medical record. When correcting the error, the nurse should _____________________________ through the error so that it is still legible, and write or type in the correct above or below the original line or in the margin.
    Draw a line

The nurse should draw a line through the error so that it is still legible. The nurse should not black out the information or use correction fluid to cover it up.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

 

 

  1. The nurse writes the date in a medical record as 9/6 when she meant to write 9/7. The nurse should write ________________near the correction to state why the error was made.
    Wrong date

The nurse should note near the correction why it was made (for example, “error, wrong date,” or “error, interrupted by a phone call”). The nurse can place this note in the margin or, add an attachment. He or she should not make a change in the record without noting the reason for it.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. Patients’ medical records are considered the property of the ­­­­­­­­_______________ of the facility where they were created.
    Owners

Patients’ medical records are considered the property of the owners of the facility where they were created. For example, a physician in private practice owns his or her records; records in a clinic are the property of the clinic. Hospital records are the property of the admitting hospital.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

  1. A medical facility generates hundreds of patient medical records during the course of patient treatment. The medical facility owns the documents, and the _________________
    owns the information they contain.
    Patient

The facility where the medical records were created owns the documents, but the patient owns the information they contain. On signing a release, patients may usually obtain access to or copies of their medical records, depending on state law.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

 

 

  1. A physician decides that a patient with a mental condition may be harmed by seeing his own medical record. This decision may hold up in court under the doctrine of __________________________________.
    Professional discretion

Under the doctrine of professional discretion, courts have held that in some cases, patients treated for mental or emotional conditions may be harmed by seeing their own records.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

  1. Under the legislation known as _________________________________________, patients who ask to see and/or copy their medical records must be accommodated, with a few exceptions.
    Health Insurance Portability and Accountability Act (HIPAA)

Under HIPAA, patients are entitled to access any health care information a physician generates about them, with a few exceptions.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

  1. A potential employer schedules and pays for a physical for a job candidate prior to hiring her. When this occurs, the ________________________owns the medical record.
    Health care facility

When a physician in private practice examines a patient for a job-related physical, scheduled and paid for by the patient’s employer or prospective employer, those records are still the physician’s property, but the employer is entitled to a copy of the record that is pertinent to the job-related exam.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

 

 

  1. As a protection in the event of litigation, records should be kept until the applicable ____________________________ period has elapsed, which generally ranges from two to seven years.
    Statute of limitations

As a protection in the event of litigation, records should be kept until the applicable statute of limitations period has elapsed, which generally ranges from two to seven years. In some cases, this involves keeping the medical records for minor patients for a specified length of time after they reach legal age.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.2 Identify ownership of medical records and determine how long a medical record must be kept by the owners.

  1. Since medical office personnel have a duty to protect the privacy of the patient, medical records should not be released to a third party without written ___________________, signed by the patient or the patient’s legal representative.
    Permission

Since medical office personnel have a duty to protect the privacy of the patient, medical records should not be released to a third party without written permission, signed by the patient or the patient’s legal representative. Only the information requested should be released.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. When medical records are requested for use in a lawsuit, a _____________________ for the release of the records must be obtained from the patient, unless a court subpoenas the records.
    Signed consent

When medical records are requested for use in a lawsuit, a signed consent for the release of the records must be obtained from the patient, unless a court subpoenas the records. In this case, the patient should be notified in writing that the records have been subpoenaed and released.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. A physician is obliged to his patient based on trust and confidence to follow the procedure to protect against unauthorized release of patient medical information. This is known as a ______________________________.
    Fiduciary duty

A fiduciary duty is a physician’s obligation to his or her patient, based on trust and confidence. Individuals responsible for releasing medical information must follow procedure to protect against unauthorized release of this information.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A federal statute that protects patients with histories of substance abuse regarding the release of information about treatment is known as ______________________________
    __________________.
    Confidentiality of Alcohol and Drug Abuse, Patient Records

Confidentiality of Alcohol and Drug Abuse, Patient Records is a federal statute that protects patients with histories of substance abuse regarding the release of information about treatment.Confidentiality of Alcohol and Drug Abuse, Patient Records protects patients with histories of substance abuse regarding the release of information about treatment.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. A patient gives permission for a physician to treat his hypertension. The permission is called ____________________.
    Consent

By givingconsent, the patient gives permission, either expressed (orally or in writing) or implied, for the physician to examine him or her, to perform tests that aid in diagnosis, and/or to treat for a medical condition.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. A patient makes an appointment with a nurse practitioner for a pap test. This is an example of ___________________consent.
    Implied

When the patient makes an appointment for an examination, that patient has given implied consent for the physician to perform the exam. Likewise, when he or she cooperates with various diagnostic testing procedures, implied consent for the tests has been given.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A patient is undergoing a surgical procedure to remove the foot of a patient with diabetes. The consent for this procedure is called _________________consent.
    Informed

For surgery and for some other procedures, such as a test for HIV, implied consent is not enough. In these cases, it is important to ask the patient to sign a consent form, thereby documenting informed consent.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. The doctrine of informed consent is the legal basis for informed consent, usually outlined in a state’s __________________________________.
    Medical practice acts

Informed consent involves the patient’s right to receive all information relative to his or her condition and then to make a decision regarding treatment based on that knowledge. Documents establishing that the patient gave informed consent prove that the patient was not coerced into treatment.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A 17-year old is living alone and responsible for his own support. When hospitalized following a motorcycle accident, it is determined that the minor has been through court to be declared _______________________and can consent to his own health care treatment.
    Emancipated

Emancipated minors are those who are living away from home and responsible for their own support. A minor becomes “emancipated” through a court hearing where evidence is presented that the minor should be emancipated, and a judge makes a determination that the minor has met certain criteria. The minor is then declared “emancipated” and can consent to his or her health care treatment just as any adult of sound mind determines his or her health care treatment.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. Those minors who have been granted the right to seek birth control or care during pregnancy, treatment for reportable communicable diseases, or treatment for drug-or alcohol-related problems without first obtaining parental consent are called _____________________minors.
    Mature

Mature minors are those who, through the doctrine of mature minors, have been granted the right to seek birth control or care during pregnancy, treatment for reportable communicable diseases, or treatment for drug- or alcohol-related problems without first obtaining parental consent.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A hospitalized patient does not speak or understand English, and needs surgery to prevent a brain hemorrhage. A(n) ___________________ may be necessary to inform the patient and obtain his or her consent for treatment.
    Interpreter

When a patient does not speak or understand English, an interpreter may be necessary to inform the patient and obtain his or her consent for treatment.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. In the law case ___________________________________, the U.S. Supreme Court upheld a 24-hour waiting period, an informed consent requirement, a parental consent provision for minors, and a record-keeping requirement for women seeking an abortion.
    Planned Parenthood v. Casey

In Planned Parenthood v. Casey, U.S. 833 (1992), the U.S. Supreme Court upheld a 24-hour waiting period, an informed consent requirement, a parental consent provision for minors, and a record-keeping requirement for women seeking an abortion.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. _____________________________is the 1973 Supreme Court decision that legalized abortion in the United States.
    Roe v. Wade

Roe v. Wade isthe 1973 Supreme Court decision that legalized abortion in the United States but allowed state regulation of abortion.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. A nurse helps a pedestrian who is struck by a car when crossing the street. In an emergency situation such as this, the nurse is not expected to obtain ________________ before proceeding with treatment.
    Consent

In emergency situations, when the patient is in immediate danger, the health care practitioner is not expected to obtain consent before proceeding with treatment.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

  1. ________________________Acts were intended to protect physicians and, in some states, other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help the victim of an accident or other emergency.
    Good Samaritan

Good Samaritan Acts are state laws protecting physicians and sometimes other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help the victim of an accident or other emergency, provided they give such care in good faith, act within the scope of their training and knowledge, use due care under the circumstances, and do not bill for their services.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

 

  1. Medical records were destroyed in a fire in a medical facility. This facility could have prevented the hardships that occurred due to the loss of medical records by using ________________medical records.
    Electronic

According to the U.S. Department of Health and Human Services, health information technology (HIT) is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making.” This technology and especially the use of electronic medical records could prevent huge medical record losses in the future.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. Under the ­­­­­­­­___________________________Act signed into law in 2010, physicians could receive up to $44,000 from the government to help with the cost of converting to electronic health records.
    Patient Protection and Affordable Care

As of 2004, President George W. Bush had set a 10-year goal for the broad adoption of electronic health records in the United States. President Barack Obama, who took office January 1, 2009, continued to urge health care providers to convert records to electronic form. In fact, under the Patient Protection and Affordable Care Act signed into law in 2010, physicians could receive up to $44,000 from the government to help with the cost of converting to electronic health records.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. A health care facility protects the privacy of patients by following facility policy for the electronic transmission and storage of health care information. These policies are mandated by the _____________________________________Act, passed in l996.
    Heath Insurance Portability and Accountability

The Health Insurance Portability and Accountability Act (HIPAA), passed in 1996 and implemented in stages through 2005, addresses privacy of health information and mandates certain procedures and standards for the electronic transmission and storage of health care information.

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. In April 2004, President George W. Bush signed an executive order establishing the position of ________________________________________________ to oversee a plan for nationwide adoption of health information technology.
    National Coordinator for Health Information Technology

In April 2004, President George W. Bush signed an executive order establishing the position of National Coordinator for Health Information Technology. The coordinator was charged with the development, maintenance, and oversight of a plan for nationwide adoption of health information technology.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. An x-ray technician transmits a patient’s x-rays over the Internet to be interpreted by the patient’s physician. The adoption of the __________________________________
    developed by Health and Human Services (HHS) has set standards for electronically transmitting this type of information as well as transmitting lab results and prescriptions electronically.
    Health information standards

As part of this effort, HHS has negotiated and licensed a comprehensive medical vocabulary and made it available to everyone in the United States at no cost. The results of these projects include standards for electronically transmitting x-rays, lab results and prescriptions.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. As one of the largest buyers of health care in Medicare, Medicaid, the Community Health Centers program, the Federal Health Benefits program, veterans’ medical care, and programs in the Department of Defense, the ____________________ can create incentives and opportunities for health care providers to use electronic records.
    Federal government

The federal government maintains that the broad use of health information technology will improve individual patient care by: improving health care quality, preventing medical errors, reducing health care costs, increasing administrative efficiency, decreasing paperwork, and expanding access to affordable care.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. One public health benefit of using health information technology is the early detection of _______________________outbreaks around the country.
    Infectious

Use of health information technology can provide early detection of infectious outbreaks around the country. For example, three patients experience unusual sudden-onset fever and cough that would not individually be reported. They show up at separate emergency rooms, and through access to electronic health information, the trend is instantly reported to public health officials, who alert authorities of a possible disease outbreak or bioterror attack.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. While the goal of widespread adoption of electronic health records by 2014 seems beneficial, many physicians and hospitals have not been eager to digitalize written records because the process is ________________________ and often fraught with information technology headaches.
    Expensive

Many physicians and hospitals have not been eager to digitalize written records because the process is expensive and often fraught with information technology headaches, such as susceptibility to hackers who would steal private informationRemember,ftware that doesn’t always perform as expected, and other threats to confidentiality when medical records are maintained and transported electronically.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. According to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, as quoted in the July 13, 2010, issue of the New York Times, just­­­_____ percent of doctors and 10 percent of hospitals use even the most basic electronic records.
    20

According to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, as quoted in the July 13, 2010, issue of the New York Times, just 20 percent of doctors and 10 percent of hospitals use even the most basic electronic records. Under federal legislation passed in 2009, the Department of Health and Human Services set aside $27 billion to help health care providers convert patients’ records to electronic health records (EHRs).

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. Health care providers who treat ___________________patients must convert patient records to electronic health records (EHRs) by 2015 or face lower fee reimbursements from the federal government.
    Medicare

Doctors can receive up to $44,000 under Medicare and $63,750 under Medicaid, and hospitals can receive millions, depending on the size of the facility, to convert health records to electronic form. Health care providers who treat Medicare patients must comply by 2015 or face lower fee reimbursements from the federal government.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

  1. In order to protect patient information, discarded copies of confidential information should be ______________________.
    Shredded

Copies of confidential information should not be discarded in a shared trash container, rather, they should be shredded.

 

Bloom’s: Remembering
Difficulty: Easy
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. When using the computer to access patient information, health care professionals should place the _____________________in an area where no one will see it.
    Monitor

The monitor should be located in an area where others cannot see the screen and should not be left unattended while confidential material is displayed on the screen.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

  1. Since medical records are ______________________, and law protects their confidentiality, health care practitioners must take every precaution to properly enter information into medical records and to keep that information confidential.
    Legal documents

The implementation of HIPAA imposes penalties for breaches of confidentiality regarding medical records that identify patients by name.

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.4 Describe the necessity for electronic medical records and the efforts being made to record all medical records electronically.

 

 

Short Answer Questions
 

  1. An attorney subpoenas a patient’s medical record in a malpractice lawsuit. The legal term for this action is ____________________________.

Subpoena duces tecum

 

Bloom’s: Applying
Difficulty: Medium
Learning Outcome: 7.1 Explain the purpose of medical records and the importance of correct documentation.

  1. An attorney issues a ____________________________for a witness to appear in court and bring certain medical records.

Subpoena duces tecum

 

Bloom’s: Understanding
Difficulty: Medium
Learning Outcome: 7.3 Describe the purpose of obtaining a patient’s consent for release of medical information, and explain the doctrine of informed consent.

 

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