Chapter 5 and 7 Exam Flashcards
A nurse carefully documents all pertinent patient information in the patient medical record. Which of the following is true of this document?
Medical records provide documentation of a patient’s health care from birth to death.
A subpoena duces tecum is ordered during a malpractice trial. What does this subpoena provide as evidence?
Medical records
Medical records are often subpoenaed for court trials. Which of the following is true regarding the use of medical records as evidence
What is omitted from the record may be as important to the trial as what is included.
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?
Clean
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?
Fix the computer so no information is on the screen.
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?
20
Which of the following is a public health benefit that will occur with expanded use of health information technology (HIT) in the medical industry?
Early detection of infectious outbreaks around the country
Which of the following is a result of the promotion of health information technology (HIT) in the medical industry?
Expanded access to affordable care
Which of the following legislation created standards for transmitting X-rays, laboratory results, and prescriptions over the Internet?
Health Information Standards Developed by Health and Human Services (HHS)
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?
Health Insurance Portability and Accountability Act (HIPAA)
What was the goal of the Patient Protection and Affordable Care Act signed into law in 2010?
Converting patient records to an electronic format
Which of the following is a central component of health information technology (HIT)?
The patient’s medical file
Which of the following statements is true regarding the provisions of the Good Samaritan Acts?
The person giving aid owes the stranger a duty of being reasonably careful.
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?
Billing for services
The Good Samaritan Acts were passed to protect physicians from being charged with which of the following torts?
Negligence
In which of the following situations is a physician not expected to obtain consent before proceeding with treatment?
When the physician is acting in an emergency situation.
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?
Generally, parental consent is required for a physician to treat a minor with HIV.
Technically, abortion is legal in how many states?
50
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?
The husband notification requirement
Which of the following cases legalized abortion at the Supreme Court level?
Roe v. Wade
Which of the following aspects of patient care is the most vital factor to the issue of informed consent?
Patient education
Which of the following is an example of a patient who usually cannot give informed consent?
An adult who is mentally incompetent
Which of the following information is not usually included in the process of the doctrine of informed consent?
The reputation of the physician performing the procedure
The doctrine of informed consent is the legal basis for informed consent. Under which of the following is this doctrine usually outlined?
State medical practice acts
For which of the following examples would implied consent not be legally appropriate?
A patient agrees to a test for HIV.
Which of the following is an example of implied consent?
A patient makes an appointment for an examination
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?
Consent
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?
It must state that the information will not be used in court trial
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?
Verify the patient’s name, address, and date of birth on the authorization.
Which of the following information is the federal statute known as the Confidentiality of Alcohol and Drug Abuse, Patient Records designed to protect?
Patient treatment
When a patient medical record is subpoenaed by the court, which of the following information must be listed on the subpoena?
The trial date and time
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?
Offer sworn testimony regarding the record if instructed to do so by the court.
When a physician is sued for malpractice, whom might the responsibility to comply with a subpoena to produce medical records fall?
The medical office employee
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?
Photocopy the medical record and send to the attorney who issued the subpoena.
A physician has an obligation to his or her patient based on trust and confidence. What is the term for this obligation
Fiduciary duty
In which of the following cases would patient authorization for release of his or her medical record be waived?
When a subpoena duces tecum is issued
Which of the following occurs with the medical record when a patient transfers to another physician?
The patient signs an authorization to release his or her records to the new physician
Which of the following describes the proper protocol for the release of medical records?
When medical records are subpoenaed, the patient should be notified in writing.
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?
2 to 7 years
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?
The physician
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?
HIPAA
The doctrine of professional discretion pertains to medical record keeping. Which of the following does this doctrine occasionally uphold in court?
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
A hospital maintains medical records on all patients who are treated. Who owns the information contained in the medical record?
The patient
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?
The physician
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?
Do not make a change in the record without noting the reason for it.
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?
Draw a line through the error so that it is still legible and write above or below the line.
Under which of the following circumstances should a separate consent form be obtained to use patient images?
When they will be used for teaching purposes
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?
The patient understands that authorization must be given to release photos outside the facility.
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?
Invasion of privacy
Which of the following should not be included in a patient’s medical record?
Personal judgments
The judge in a negligence case states that the rights of the patient were violated, though no actual loss was proven. The judge awards the plaintiff $1.00. This is known as what type of award
Nominal
The family of a patient sues for wrongful death when the patient’s death was judged to have been due to the negligence of health care practitioners. What might the family collect from a settlement of this case
An award for loss to the patient’s estate of future earnings
Which of the following would occur in the pleading phase of a lawsuit?
The defendant’s attorney files an answer to the summons
A deposition may be taken in which phase of the lawsuit?
Interrogatory
The judge in a lawsuit issues a summons. Which of the following is true about this process
A summons is delivered to the defendant.
Which of the following is an example of a pre-trial motion
A defendant may request a change of venue.
A set of written questions requiring written answers are given to a plaintiff while under oath. What is the term for this practice
Interrogatory
A health care practitioner is asked to give testimony in an attorney’s conference room in a pretrial proceeding. What is the term for this method of obtaining testimony?
Discovery deposition
An attorney for the defendant makes an objection to a question the plaintiff’s attorney asks the witness. Which of the following occurs when this happens?
The objection may be sustained and the witness should not answer the question.
A nurse who observed a surgeon commit negligence due to improper surgical technique, states only what she observed when giving testimony. What type of testimony is this witness giving
A nurse who observed a surgeon commit negligence due to improper surgical technique, states only what she observed when giving testimony. What type of testimony is this witness giving? Fact
Which of the following are recommended guidelines for a health care practitioner who is summoned to appear in court?
Answer the questions asked, no more and no less.
A physician is testifying as a fact witness in trial of a coworker. Which of the following is the best example of properly worded testimony
“As I recall, that is all that occurred in the operating room”
A nurse is testifying as a fact witness in a malpractice lawsuit. Which of the following is a recommended guideline for this process?
Answer all questions straightforward, even if answers appear to help opposing side.
Instead of going to court, two disputing parties agree to a neutral third party listening to both sides of the argument and helping resolve the dispute. What is the term for this type of dispute resolution
Mediation
Alternative dispute resolution has become increasingly popular over the years. What is the reason for this increase in ADR?
Overcrowding of court calendars
Some states require mediation and/or arbitration for certain civil cases, while in other states alternative dispute resolution methods are voluntary. Under the terms of a written contract, who chooses an arbitrator?
The court
In an informal proceeding of arbitration, each side presents evidence and witnesses. In the alternative dispute resolution method called med-arb, who resolves the dispute if the two parties are unable to reach agreement after mediation?
The mediator
A patient was harmed when the oxygen tank she was using exploded. When filing a lawsuit what type of damages might this patient be awarded?
Consequential-
Which of the following examples of negligence would fall under the doctrine of res ipsa loquitur?
A patient suffers an infection caused by the use of unsterilized instruments.-
Which of the following is a stated condition for res ipsa loquitur to apply to a lawsuit?
It must be apparent there would be no injury had reasonable care been used-
A patient files for negligence under the doctrine res ipsa loquitur. What is the English meaning of this Latin wording?
The thing speaks for itself”-
A surgeon removes a patient’s kidney and later finds out that she removed the wrong kidney. This patient can sue under which of the following doctrines?
Res ipsa loquitur-
The Joint Commission addresses improving the safety of infusion pumps, improving the effectiveness of clinical alarm systems, and reducing the risk of health-care acquired infections. Which of the following is a recommended guideline to accomplish these goals?
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection-
The Joint Commission addresses accurately identifying patients and improving communication among caregivers by making sure all accredited health care organizations implement which of the following requirements?
Use a process for taking verbal or telephone orders or critical test results that requires a verification read-back by the person receiving the information.-
In some states medical review panels must screen claims before they are brought to court. Which of the following are usually members of these panels?
Physicians with expertise in the medical specialty in question-
A patient sues a physician for malpractice. Upon whom is the burden of proof for the charge of negligence?
The plaintiff-
A health care provider breaches the duty of care to a patient. This element of negligence is defined as:
dereliction.-
There are four elements (4 Ds) that must be present in a given situation to prove that a health care professional is guilty of negligence. Which of the following is not one of the “four Ds of negligence?”
Defense-
A surgeon removes the wrong limb from a patient. Which of the following four Ds of negligence refers to the current condition of the patient?
Damages-
A physician who is treating a patient who has pancreatic cancer provides competent care for his patient, thereby preventing a charge of negligence. Which of the following four Ds of negligence refers to this responsibility to properly care for a patient?
Duty-
Which of the following is an example of misfeasance?
A nurse is changing a patient’s IV line, but does not wash her hands prior to procedure.-
A nurse dispenses a painkiller to a patient without the physician’s order for the medication. This is an example of which of the following torts?
Malfeasance-
Which of the following is the basis for professional malpractice claims and the most common liability in medicine?
Negligence-
In which of the following situations may patient confidentiality be waived?
When a third party requests a medical examination of a person for employment-
Since health care procedures and facilities present numerous opportunities for a breach of confidentiality, health care practitioners must make every effort to safeguard each patient’s privacy. Which of the following is a recommended guideline for protecting a patient’s privacy?
When on the telephone with a patient, do not use his or her name if others may hear.-
In many states, revocation of a physician’s license may occur due to which of the following acts?
Breach of confidence-
Which of the following is an example of privileged communication?
A patient tells his physician that he is addicted to pain killers.
A nurse recording data in a patient’s medical record maintains confidentiality at all times. Which of the following describes this practice?
Not releasing patient information to unauthorized individuals-
A physician has an informal consultation with another physician in his office. Which of the following opinions have the courts generally held in cases of negligence related to the information discussed in informal consultations?
They do not establish a doctor-patient relationship.-
A physician is a specialist in obstetrics. Which of the following is true regarding the standard of care expected of this physician?
The physician will be held to the same standard of care as other obstetricians.-
In a court of law, it was decided that a patient was injured when a nurse failed to act according to the reasonable person standard. This nurse is guilty of which of the following torts?
Negligence-
A health care worker is responsible for his or her actions or failure to act. Which of the following best describes this responsibility to prevent negligence from occurring?
Reasonable person standard-
A physician treating patients in a long-term care facility determines that a patient has a communicable disease that could cause an outbreak in the facility. The physician works with the administrator of the facility and the public health department to protect other residents and employees from exposure to the disease. Under some state laws, this physician is obligated to protect nonpatients in accordance with which of the following standards?
Duty of care-
A physician working in an emergency room is obligated to treat all the patients who come through the door. This is an example of which of the following concepts?
Duty of care-
In a hospital setting a certain standard of care is expected of health care practitioners. Which of the following best describes this concept?
An expected level of performance-
As employers, physicians have general liability for many aspects of their business. Which of the following does not fall under the responsibility of the employer?
Employee safety going to and from the work place-
A physician who owns a physician’s office is legally responsible for her employees. What is the term for this responsibility?
Liable-
medical record
-collection of data recorded when a patient seeks medical treatment
(property of the physician or institution; does not belong to the patient)
(purpose: continuity of care, legal, research, billing)
5 “C”s of Charting
- ) concise
- ) complete (and objective)
- ) clear (legible)
- ) correct
- ) chronological
doctrine of professional discretion
principle under which a physician can exercise judgement as to whether or not to show patients who are being treated for mental or emotional conditions their records
(Doctor decides if patient may be harmed by viewing own medical record)
fiduciary duty
a physician’s obligation to his or her patient, based on trust and confidence
confidentiality of alcohol and drug abuse, patient records
federal statue that protects patients with histories of substance abuse regarding the release of information about treatment
(patient must give specific, written permission for this information to be shared)
consent
permission from a person, expressed or implied, for something to be done by another
doctrine of informed consent
legal basis for informed consent, outlined in a state’s medical practice acts
(doctor informs patient of treatment options, risks, etc)
able to give informed consent
adults of sound mind, emancipated minors, married minors, mature minors, minors in the military
Roe V. Wade
- U.S. Supreme Cour decision that, based on the right to privacy, a woman is constitutionally justified in seeking an abortion during the first trimester of pregnancy, but states can impose restrictions and regulate abortions after the first trimester.
Good Samaritan Acts
state laws protecting physicians and sometimes other health care practitioners and laypersons from charges if they stop to help an accident victim provided they…
- give care in good faith
- act within the scope of their training and knowledge
- use due care
- do not bill for services
HIT
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. (health information technology)
EHR
electronic health record
HIPAA
- Health Insurance Portability and Accountability Act; federal law to protect privacy and other health care rights for patients. The act helps workers keep continuous health insurance coverage for themselves and dependents when they change jobs, and protects confidential medical information form unauthorized disclose/use. Also intended to curb rising cost of health care fraud and abuse.
What are the 5c’s
Concise Complete (and objective) Clear (and legibly written) Correct Chronologically ordered
