Question 1

The persistent failure to conform to a medical staff rule requiring physicians to complete records promptly can be the basis for ___________.

Accepted Answer

A)  limitations placed on or suspension of medical staff privilege 
B)  assuring medical staff privileges 
C)  sanctions by the planning board 
D)  granting surgical privileges 
A)  limitations placed on or suspension of medical staff privilege 
B)  assuring medical staff privileges 
C)  sanctions by the planning board 
D)  granting surgical privileges A

Question 2

Patients have a legally enforceable right to ___________.

Accepted Answer

A)  the information contained in their caregivers medical records 
B)  access the information contained in their medical records 
C)  review and obtain copies of their records, X-rays, and laboratory and diagnostic tests 
D)  access to information maintained or possessed by a few health care organizations 
A)  the information contained in their caregivers medical records 
B)  access the information contained in their medical records 
C)  review and obtain copies of their records, X-rays, and laboratory and diagnostic tests 
D)  access to information maintained or possessed by a few health care organizations B

Question 3

Ordinary business documents are ___________.

Accepted Answer

A)  considered privileged 
B)  generally protected from discovery by state statutes 
C)  not protected as privileged communications by state statutes 
D)  are considered strictly confidential information and their contents cannot be exposed with some exceptions in a court of law 
A)  considered privileged 
B)  generally protected from discovery by state statutes 
C)  not protected as privileged communications by state statutes 
D)  are considered strictly confidential information and their contents cannot be exposed with some exceptions in a court of law C

Question 4

Peer review documents are

Accepted Answer

A)  discoverable in all states 
B)  available to all hospital employees 
C)  generally exempt from discovery 
D)  available for public review 
A)  discoverable in all states 
B)  available to all hospital employees 
C)  generally exempt from discovery 
D)  available for public review

Question 5

The effective and efficient delivery of patient care requires that an organization determine its information needs. Organizations that do not centralize their information needs will often suffer from ___________.

Accepted Answer

A)  centralized and organized databases 
B)  scattered databases 
C)  consistent reports 
D)  efficiency in the use of economic resources 
A)  centralized and organized databases 
B)  scattered databases 
C)  consistent reports 
D)  efficiency in the use of economic resources

Question 6

The process of facilitating the flow of information within and among departments and caregivers is ___________.

Accepted Answer

A)  treatment planning 
B)  computerization of financial records 
C)  digitized clinical data 
D)  information management 
A)  treatment planning 
B)  computerization of financial records 
C)  digitized clinical data 
D)  information management

Question 7

The admission record does not generally provide ___________.

Accepted Answer

A)  the patient's age 
B)  the patient's address 
C)  the patient's sexual preferences 
D)  the patient's marital status, religion, and health insurance 
A)  the patient's age 
B)  the patient's address 
C)  the patient's sexual preferences 
D)  the patient's marital status, religion, and health insurance

Question 8

The advantages of computer systems ___________.

Accepted Answer

A)  have yet to be developed 
B)  play an ever-decreasing role in the education process 
C)  include timely retrieval of demographic information, consultant reports, and test results 
D)  no longer allows for computer-generated prescriptions 
A)  have yet to be developed 
B)  play an ever-decreasing role in the education process 
C)  include timely retrieval of demographic information, consultant reports, and test results 
D)  no longer allows for computer-generated prescriptions

Question 9

The HIPAA security provisions took effect April 20, 2005. HIPAA defines the three segments of security safeguards for compliance as ___________.

Accepted Answer

A)  administrative, physical, and technical 
B)  administrative, physical, and emotional 
C)  administrative, technical, and total 
D)  physical, technical, and tertiary 
A)  administrative, physical, and technical 
B)  administrative, physical, and emotional 
C)  administrative, technical, and total 
D)  physical, technical, and tertiary

Question 10

A patient's medical record may not be released ___________.

Accepted Answer

A)  to health insurance companies for reimbursement purposes 
B)  to health insurance companies in order to process health claims 
C)  because a person is in the public spotlight (e.g., movie star) 
D)  for criminal investigative work 
A)  to health insurance companies for reimbursement purposes 
B)  to health insurance companies in order to process health claims 
C)  because a person is in the public spotlight (e.g., movie star) 
D)  for criminal investigative work

Question 11

Health care organizations undergoing computerization must ___________.

Accepted Answer

A)  develop a disaster recovery plan (e.g., provide for emergency power systems and backup files), provide for data security, design an effective system, and seek input from end users 
B)  determine direct computer ease of access for patients 
C)  select the least expensive hardware 
D)  determine building services ease of access to patient information 
A)  develop a disaster recovery plan (e.g., provide for emergency power systems and backup files), provide for data security, design an effective system, and seek input from end users 
B)  determine direct computer ease of access for patients 
C)  select the least expensive hardware 
D)  determine building services ease of access to patient information

Question 12

Charting by exception requires ___________.

Accepted Answer

A)  charting significant changes in a patient's condition 
B)  writing copious notes in a patient's medical record 
C)  detailed charting in a patient's record from admission to discharge 
D)  none of the above 
A)  charting significant changes in a patient's condition 
B)  writing copious notes in a patient's medical record 
C)  detailed charting in a patient's record from admission to discharge 
D)  none of the above

Question 13

The Privacy Act of 1974 provides that ___________.

Accepted Answer

A)  the privacy of individual information is not affected by the collection, maintenance, use, and dissemination of personal information by Federal agencies 
B)  the increasing use of computers and sophisticated information technology, while essential to the efficient operations of the Government, has in no way harmed individual privacy that can occur from the collection, maintenance, use, or dissemination of personal information 
C)  the opportunities for an individual to secure employment, insurance, and credit; his right to due process; and other legal protections have been found safe by the misuse of certain information systems 
D)  the right to privacy is a personal and fundamental right protected by the Constitution of the United States 
A)  the privacy of individual information is not affected by the collection, maintenance, use, and dissemination of personal information by Federal agencies 
B)  the increasing use of computers and sophisticated information technology, while essential to the efficient operations of the Government, has in no way harmed individual privacy that can occur from the collection, maintenance, use, or dissemination of personal information 
C)  the opportunities for an individual to secure employment, insurance, and credit; his right to due process; and other legal protections have been found safe by the misuse of certain information systems 
D)  the right to privacy is a personal and fundamental right protected by the Constitution of the United States

Question 14

Medical record entries should ___________.

Accepted Answer

A)  be written within seven days of observing a patient's deteriorating condition 
B)  be written within 21 days of observing a patient's deteriorating condition 
C)  be legible 
D)  not provide too much clarity 
A)  be written within seven days of observing a patient's deteriorating condition 
B)  be written within 21 days of observing a patient's deteriorating condition 
C)  be legible 
D)  not provide too much clarity

Question 15

The Privacy Act of 1974 was enacted to ___________.

Accepted Answer

A)  safeguard the privacy of healthcare professionals 
B)  provide a backup for state records 
C)  provide individuals with legal access to federal records 
D)  safeguard individual privacy and discourage misuse of federal records 
A)  safeguard the privacy of healthcare professionals 
B)  provide a backup for state records 
C)  provide individuals with legal access to federal records 
D)  safeguard individual privacy and discourage misuse of federal records

Question 16

The Health Insurance Portability and Accountability Act of 1996 provides that ___________.

Accepted Answer

A)  patients must be able to access their record and request correction of errors 
B)  patients must be informed as to how their personal information will be used 
C)  patient information cannot be used for marketing purposes without the explicit consent of the involved patients 
D)  all of the above 
A)  patients must be able to access their record and request correction of errors 
B)  patients must be informed as to how their personal information will be used 
C)  patient information cannot be used for marketing purposes without the explicit consent of the involved patients 
D)  all of the above

Question 17

Persistent failure of a physician to complete his or her medical records can lead to ___________.

Accepted Answer

A)  promotion 
B)  suspension of medical staff privileges 
C)  breach of confidentiality 
D)  improved reimbursement from patience insurance carriers 
A)  promotion 
B)  suspension of medical staff privileges 
C)  breach of confidentiality 
D)  improved reimbursement from patience insurance carriers

Question 18

The following should be written in a patient's medical record:

Accepted Answer

A)  long, defensive, or derogatory notes 
B)  facts pertinent to the patient's care 
C)  complaints or emotional comments about other caregivers 
D)  emotional comments and extraneous remarks 
A)  long, defensive, or derogatory notes 
B)  facts pertinent to the patient's care 
C)  complaints or emotional comments about other caregivers 
D)  emotional comments and extraneous remarks

Question 19

Rewriting record entries by a nurse ___________.

Accepted Answer

A)  is a good practice even after the patient has been discharged 
B)  is well-publicized as the right thing to do 
C)  can illustrate how conscientious the caretaker is, especially during a lawsuit 
D)  can cast doubt on the accuracy of other medical record entries 
A)  is a good practice even after the patient has been discharged 
B)  is well-publicized as the right thing to do 
C)  can illustrate how conscientious the caretaker is, especially during a lawsuit 
D)  can cast doubt on the accuracy of other medical record entries

Question 20

The length of time medical records must be retained ___________.

Accepted Answer

A)  is set by insurance carriers 
B)  is set by federal law 
C)  is the same in all states 
D)  can vary from state to state 
A)  is set by insurance carriers 
B)  is set by federal law 
C)  is the same in all states 
D)  can vary from state to state

Exam 11: Medical Records

The persistent failure to conform to a medical staff rule requiring physicians to complete records promptly can be the basis for ___________.

Patients have a legally enforceable right to ___________.

Ordinary business documents are ___________.

Peer review documents are

The effective and efficient delivery of patient care requires that an organization determine its information needs. Organizations that do not centralize their information needs will often suffer from ___________.

The process of facilitating the flow of information within and among departments and caregivers is ___________.

The admission record does not generally provide ___________.

The advantages of computer systems ___________.

The HIPAA security provisions took effect April 20, 2005. HIPAA defines the three segments of security safeguards for compliance as ___________.

A patient's medical record may not be released ___________.

Health care organizations undergoing computerization must ___________.

Charting by exception requires ___________.

The Privacy Act of 1974 provides that ___________.

Medical record entries should ___________.

The Privacy Act of 1974 was enacted to ___________.

The Health Insurance Portability and Accountability Act of 1996 provides that ___________.

Persistent failure of a physician to complete his or her medical records can lead to ___________.

The following should be written in a patient's medical record:

Rewriting record entries by a nurse ___________.

The length of time medical records must be retained ___________.

Reflections of the Past

Government, Law, and Ethics

Tort Law

Criminal Aspects of Health Care

Contracts

Civil Procedure and Trial Practice

Corporate Structure and Legal Issues

Medical Organization and Physician Liability

Nursing and the Law

Hospital Departments and Allied Health Professionals

Patient Consent

Patient Rights and Responsibilities

Health Care Ethics

Procreation and Ethical Dilemmas

End of Life Issues

Legal Reporting Requirements

Labor Relations

Employment-Atwill and Discharge

Employee Rights and Responsibilities

Professional Liability Insurance

Filters