Question 1

A written order requiring a person to appear in court,give testimony,and bring the records described is called

Accepted Answer

A) res ipsa loquitur. 
B) subpoena duces tecum. 
C) respondeat superior. 
D) a subpoena. 
A) res ipsa loquitur. 
B) subpoena duces tecum. 
C) respondeat superior. 
D) a subpoena. B

Question 2

Physicians who wish to disclose confidential medical record information should

Accepted Answer

A) first discuss it with the patient's family. 
B) discuss it with the patient first. 
C) discuss the risks involved with his or her lawyer. 
D) first discuss the problem with the patient's contact person. 
A) first discuss it with the patient's family. 
B) discuss it with the patient first. 
C) discuss the risks involved with his or her lawyer. 
D) first discuss the problem with the patient's contact person. B

Question 3

Medical records are usually exempt from state open-record laws except when

Accepted Answer

A) the benefit of disclosure for the public interest (safety)outweighs confidentiality. 
B) requested by a family member to be disclosed to the public. 
C) mental health records are to be disclosed to the public. 
D) an attorney requests the records to be made public. 
A) the benefit of disclosure for the public interest (safety)outweighs confidentiality. 
B) requested by a family member to be disclosed to the public. 
C) mental health records are to be disclosed to the public. 
D) an attorney requests the records to be made public. A

Question 4

The medical record must include information about patient care such as

Accepted Answer

A) admitting diagnosis. 
B) physician examination report and documentation of complications. 
C) discharge summary and follow-up care. 
D) all of the above. 
A) admitting diagnosis. 
B) physician examination report and documentation of complications. 
C) discharge summary and follow-up care. 
D) all of the above.

Question 5

Confidential medical record information that can be disclosed to a health department without the patient's consent includes

Accepted Answer

A) HIV cases. 
B) AIDS cases. 
C) abortions. 
D) A and B. 
A) HIV cases. 
B) AIDS cases. 
C) abortions. 
D) A and B.

Question 6

Federal reimbursement guidelines require that all medical records be completed within

Accepted Answer

A) 15 days following the patient's discharge from a hospital. 
B) 30 days following the patient's discharge from a hospital. 
C) 45 days following the patient's discharge from a hospital. 
D) 60 days following the patient's discharge from a hospital. 
A) 15 days following the patient's discharge from a hospital. 
B) 30 days following the patient's discharge from a hospital. 
C) 45 days following the patient's discharge from a hospital. 
D) 60 days following the patient's discharge from a hospital.

Question 7

All medical records should be stored for

Accepted Answer

A) 5 years from the date of the last entry. 
B) 7 years from the date of the last entry. 
C) 10 years from the date of the last entry. 
D) 23 years from the date of the last entry. 
A) 5 years from the date of the last entry. 
B) 7 years from the date of the last entry. 
C) 10 years from the date of the last entry. 
D) 23 years from the date of the last entry.

Question 8

The accepted method of correcting medical record errors is

Accepted Answer

A) erase and write the correction. 
B) draw a line through the error and write the correction underneath. 
C) draw a line through the error and write the correction above with the date and initials of the person making the correction. 
D) erase and write the correction,adding the date and initials of the person making the correction. 
A) erase and write the correction. 
B) draw a line through the error and write the correction underneath. 
C) draw a line through the error and write the correction above with the date and initials of the person making the correction. 
D) erase and write the correction,adding the date and initials of the person making the correction.

Question 9

When preparing a copy of a medical record for a third party,

Accepted Answer

A) keep the copy and send the original. 
B) make two copies and send the original. 
C) keep the original and send a copy. 
D) make a copy of the complete record and send it even when one part is requested. 
A) keep the copy and send the original. 
B) make two copies and send the original. 
C) keep the original and send a copy. 
D) make a copy of the complete record and send it even when one part is requested.

Question 10

Medical record management requires

Accepted Answer

A) accuracy. 
B) confidentiality. 
C) proper filing and storage. 
D) all of the above. 
A) accuracy. 
B) confidentiality. 
C) proper filing and storage. 
D) all of the above.

Question 11

Patient information in the medical record should include

Accepted Answer

A) the date of birth. 
B) the date of marriage. 
C) a record of divorces. 
D) the date of the spouse's birth. 
A) the date of birth. 
B) the date of marriage. 
C) a record of divorces. 
D) the date of the spouse's birth.

Question 12

Laws regarding medical records

Accepted Answer

A) are mandated by the federal government. 
B) apply to individual healthcare facilities. 
C) vary from state to state. 
D) are the same from state to state. 
A) are mandated by the federal government. 
B) apply to individual healthcare facilities. 
C) vary from state to state. 
D) are the same from state to state.

Question 13

Healthcare providers and healthcare institutions who disclose confidential health information may

Accepted Answer

A) do so without consequences. 
B) face civil or criminal liability for disclosure. 
C) face civil liability for disclosure. 
D) face criminal liability for disclosure. 
A) do so without consequences. 
B) face civil or criminal liability for disclosure. 
C) face civil liability for disclosure. 
D) face criminal liability for disclosure.

Question 14

For the court's purpose,if documentation does not appear in the medical record

Accepted Answer

A) it did not occur. 
B) it can be documented at a later date without harm. 
C) the court will not use the medical record against the healthcare provider. 
D) all of the above. 
A) it did not occur. 
B) it can be documented at a later date without harm. 
C) the court will not use the medical record against the healthcare provider. 
D) all of the above.

Question 15

Immunization records should be kept

Accepted Answer

A) for 10 years. 
B) permanently. 
C) for 5 years. 
D) until the age of maturity. 
A) for 10 years. 
B) permanently. 
C) for 5 years. 
D) until the age of maturity.

Question 16

An incomplete medical record may

Accepted Answer

A) not be a problem,as the remainder of the entry could be discussed during a court hearing. 
B) make it impossible for the healthcare provider to defend allegations in court. 
C) allow only part of a bill to be paid. 
D) not be able to be subpoenaed to court. 
A) not be a problem,as the remainder of the entry could be discussed during a court hearing. 
B) make it impossible for the healthcare provider to defend allegations in court. 
C) allow only part of a bill to be paid. 
D) not be able to be subpoenaed to court.

Question 17

Older records of former patients

Accepted Answer

A) need to be kept in the physician's office indefinitely. 
B) can be stored in a clean,dry storage space. 
C) can be destroyed after 5 years. 
D) need to be kept in the physician's office for at least 7 years. 
A) need to be kept in the physician's office indefinitely. 
B) can be stored in a clean,dry storage space. 
C) can be destroyed after 5 years. 
D) need to be kept in the physician's office for at least 7 years.

Question 18

The purpose of a medical record is to

Accepted Answer

A) provide the billing record of the patient from admission to the practice. 
B) provide the medical picture and record of the patient from birth to death. 
C) provide data and statistics on health matters. 
D) B and C. 
A) provide the billing record of the patient from admission to the practice. 
B) provide the medical picture and record of the patient from birth to death. 
C) provide data and statistics on health matters. 
D) B and C.

Question 19

To protect patient confidentiality,medical records can be released

Accepted Answer

A) to an attorney. 
B) to a judge. 
C) to the patient's family members. 
D) only with the patient's written consent. 
A) to an attorney. 
B) to a judge. 
C) to the patient's family members. 
D) only with the patient's written consent.

Question 20

Ownership of the medical record usually remains with the

Accepted Answer

A) physician. 
B) patient. 
C) court. 
D) all of the above. 
A) physician. 
B) patient. 
C) court. 
D) all of the above.

A written order requiring a person to appear in court,give testimony,and bring the records described is called

Physicians who wish to disclose confidential medical record information should

Medical records are usually exempt from state open-record laws except when

The medical record must include information about patient care such as

Confidential medical record information that can be disclosed to a health department without the patient's consent includes

Federal reimbursement guidelines require that all medical records be completed within

All medical records should be stored for

The accepted method of correcting medical record errors is

When preparing a copy of a medical record for a third party,

Medical record management requires

Patient information in the medical record should include

Laws regarding medical records

Healthcare providers and healthcare institutions who disclose confidential health information may

For the court's purpose,if documentation does not appear in the medical record

Immunization records should be kept

An incomplete medical record may

Older records of former patients

The purpose of a medical record is to

To protect patient confidentiality,medical records can be released

Ownership of the medical record usually remains with the

Introduction to Medical Law, Ethics, and Bioethics

The Legal System

Importance of the Legal System for the Physician and the Health-Ccare Professional

Todays Healthcare Environment

The Physician-Patient Relationship

Professional Liability and Medical Malpractice

Public Duties of the Physician and the Health Care Professional

Workplace Law and Ethics

Patient Confidentiality and Hipaa

Ethical and Bioethical Issues in Medicine

Ethical Issues Relating to Life

Death and Dying

Future Trends in Healthcare

Filters

Exam 9: The Medical Record

A written order requiring a person to appear in court,give testimony,and bring the records described is called

Physicians who wish to disclose confidential medical record information should

Medical records are usually exempt from state open-record laws except when

The medical record must include information about patient care such as

Confidential medical record information that can be disclosed to a health department without the patient's consent includes

Federal reimbursement guidelines require that all medical records be completed within

All medical records should be stored for

The accepted method of correcting medical record errors is

When preparing a copy of a medical record for a third party,

Medical record management requires

Patient information in the medical record should include

Laws regarding medical records

Healthcare providers and healthcare institutions who disclose confidential health information may

For the court's purpose,if documentation does not appear in the medical record

Immunization records should be kept

An incomplete medical record may

Older records of former patients

The purpose of a medical record is to

To protect patient confidentiality,medical records can be released

Ownership of the medical record usually remains with the

Introduction to Medical Law, Ethics, and Bioethics

The Legal System

Importance of the Legal System for the Physician and the Health-Ccare Professional

Todays Healthcare Environment

The Physician-Patient Relationship

Professional Liability and Medical Malpractice

Public Duties of the Physician and the Health Care Professional

Workplace Law and Ethics

Patient Confidentiality and Hipaa

Ethical and Bioethical Issues in Medicine

Ethical Issues Relating to Life

Death and Dying

Future Trends in Healthcare

Filters