A physician who performs a surgical procedure on a patient without obtaining the patient’s consent may be liable for:
Consent that is conveyed through spoken or written words is
Consent that is conveyed through a person’s conduct is
If an individual is in an emergency condition and does not have capacity to communicate consent,
consent is expressed
A patient signs a consent form, authorizing hospital staff to perform interventions necessary for overall medical care. This consent is
Informed consent requires informing the patient of all of the following except
hospital charges versus amount covered by insurance
If proposed medical intervention is related to a research study
institutional review board approval is required
Laws that require drivers to consent to blood alcohol tests, with penalties for refusal, probably exist to
protect the public
Under the Common Rule, informed consent for human subjects in research studies may be waived if
the institutional review board approves a waiver
GINA applies to
health insureres, group health plans, employers with 15 or more employees
Prohibits discrimination based on genetic info
Under HIPAA, compound authorizations
combine informed consent with authorization for use and disclosure of a research subject’s health information
provide a way for individuals to communicate their healthcare wishes before they become incapacitated
If it is not durable, a power of attorney (POA) is effective
only when the principal is mentally incompetent
A living will
expresses an individual’s healthcare wishes when specific health conditions exist
A do not resuscitate order
is a type of advance directive, is used only in emergency situations, may be revoked at any time
The Uniform Anatomical Gift Act
promotes consistency among state laws, provides suggested standards for all aspects of organ donation, includes an opt-in system for organ donation
When a competent adult refuses to consent to lifesaving treatment, the two competing sets of interest that come into play are the individual’s privacy interest and
the government’s interest in protecting and preserving human life
In In re Quinlan, the court held that
an incompetent individual has a right of privacy to terminate treatment
In the Cruzan case, the Missouri Supreme Court held that no one can make end-of-life choices on behalf of an incompetent person without
clear and convincing evidence
The end-of-life controversy in the Terri Schiavo case included
a question about the authority of legislative bodies to intervene in judicial matters
The Uniform Health-Care Decisions Act (UHCDA)
provides an additional option to creating advance directives
Emancipated minors are defined as those who have
been afforded legal status as an adult
State laws most likely permit a minor to consent on their own behalf for which of the following conditions?
Frances has been experiencing abdominal pain. Removal of her gallbladder has been recommended. Who is responsible to obtain Frances’ informed consent?
the physician who will be performing the surgery
What is the primary purpose of patient health information?
In general, the Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) does which of the following?
allows record reproductions to be admitted as evidence
Which of the following statements about the “legal health record” or the “designated record set” is incorrect?
designated record set is defined by health care facility
Destruction of health records
may be a prudent business practice
The legal health record
is the record that is disclosed upon request
The legal health record must meet standards as defined by the following:
federal regulations, state laws, accreditation body standards
Verbal orders by telephone or in person are discouraged. In cases where verbal orders are necessary, which of the following is the most effective method by which the risk of miscommunication can be lessened?
person receiving the order should read it back to insure the order is correct.
Which of the following exemplifies an acceptable patient record entry?
patient articulated pain level as a 6
Staff disagreements within the health record should be
Legally, which of the following is the most important in determining the length of time that a hospital must retain medical records?
statute of limitations
Integrity refers to the
accuracy and completeness of information
A goal of E-SIGN legislation was to
give electronic signatures increased legal standing
contradicts basic authentication standards
Authentication methods include:
handwritten signature, rubber signature stamp, and electronic signature
Changes to health record entries
are acceptable in certain circumstances
A late entry into a health record should
be identified as a late entry
Abbreviations in the health record
are not permitted by Joint Commission standards
The integrity of EHR documentation is more susceptible than the paper health record to which of the following functions?
cut and paste
Record maintenance and content requirements are established in part by
dept of health and human services, joint commission, centers for medicare and medicaid services
Of the following, who has ultimate legal responsibility for the quality of care rendered in a healthcare organization?
What Act served to make electronic transactions as enforceable as paper transactions?
Uniform Electronic Transactions Act
signifies review and evaluation of the first provider’s entry
An error in a paper health record should be
crossed out so that it can be seen but not relied on
Which of the following is incorrect regarding a late entry?
The date and time referred to should not be entered as it will create confusion
A personal health record (PHR)
may be housed in a system that a provider owns and controls
Which of the following doesn’t the “Administrative Simplification” portion of Title II of HIPAA address?
computer memory requirements for health plans maintaining patient health information
Although HIPAA is not the first piece of federal privacy legislation, it is more expansive than the Federal Privacy Act of 1974, which applied privacy rules to:
Under HIPAA, which of the following is not named as a covered entity?
outsourced transcription company
The HIPAA privacy rule:
supersedes all state laws that conflict with it.
Linda Wallace is being admitted to the hospital. She is presented with a “Notice of Privacy Practices.” In the Notice, it is explained that her PHI will be used and disclosed for treatment, payment and operations (TPO) purposes. Linda states that she does not want her PHI used for those purposes.
The hospital may decline to treat Linda because of her refusal.
Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable?
No. A dentist is a healthcare clearinghouse, which is a HIPAA covered entity.
Mercy Hospital personnel need to review the medical records of Katie Grace for utilization review purposes (#1). They will also be sending her records to her physician for continuity of care (#2). As they pertain to Mercy Hospital, these two functions are:
use (#1) and disclosure (#2)
The HIPAA privacy rule:
both a and b are incorrect.
Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wishes to review her medical record in person. She has requested to review them by herself in a closed room.
Sally’s request does not have to be granted because the hospital is responsible for the integrity of the medical record.
The HIPAA-recognized consent is a patient’s agreement to:
use or disclosure for TPO purposes
An original goal of HIPAA Administrative Simplification was to standardize:
the electronic transmission of health data.
You are a member of the hospital’s Health Information Management Committee. The committee has created a HIPAA-complaint authorization form. Which of the following items does the privacy rule not require?
signature of the patient’s attending physician
Which of the following is not an element that makes information “PHI” under the HIPAA privacy rule?
contained within a personnel file
One of the medical staff committees at St. Vincent Hospital is responsible for reviewing cases of patients readmitted within 14 days after discharge. This review of the patients’ medical records is:
Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a(n):
Blake Hospital retains Barry and Associates, an accounting firm, to handle its audit functions. Some of its functions include access to PHI. Which of the following statement(s) is/are true about Barry and Associates?
It is a business associate because it uses or discloses individually identifiable health information on behalf of the hospital.
Which of the following disclosures provides an individual with the opportunity to agree or object?
Augusta Clinic has requested that Furr Hospital send its health records from Helena Smith’s most recent admission to the clinic for her follow-up appointment. Which of the following statements is true?
Per the privacy rule, Helena must complete a written authorization.
Per the HIPAA privacy rule, a hybrid entity is defined as one that
performs both covered and non-covered functions under the privacy rule
Which of the following is not a required element of the Notice of Privacy Practices?
Statement that treatment can be refused if the notice is not signed
Which of the following is not a HIPAA identifier?
Of the following options, a sign-in sheet at a physician’s office is best described as:
Which of the following statements is true? A HIPAA authorization:
may be revoked as long as it is in writing.
The minimum necessary standard
applies to both uses and disclosures of PHI.
if sheri requests a copy of her health record from a provider, per HIPAA the provider:
may charge for the cost of copying.
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