Chapter 5 and 7 Exam

Question 1

A nurse carefully documents all pertinent patient information in the patient medical record. Which of the following is true of this document?

Answer 1

Medical records provide documentation of a patient’s health care from birth to death.

Question 2

A subpoena duces tecum is ordered during a malpractice trial. What does this subpoena provide as evidence?

Answer 2

Medical records

Question 3

Medical records are often subpoenaed for court trials. Which of the following is true regarding the use of medical records as evidence

Answer 3

What is omitted from the record may be as important to the trial as what is included.

Question 4

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?

Answer 4

Clean

Question 5

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?

Answer 5

Fix the computer so no information is on the screen.

Question 6

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?

Answer 6

20

Question 7

Which of the following is a public health benefit that will occur with expanded use of health information technology (HIT) in the medical industry?

Answer 7

Early detection of infectious outbreaks around the country

Question 8

Which of the following is a result of the promotion of health information technology (HIT) in the medical industry?

Answer 8

Expanded access to affordable care

Question 9

Which of the following legislation created standards for transmitting X-rays, laboratory results, and prescriptions over the Internet?

Answer 9

Health Information Standards Developed by Health and Human Services (HHS)

Question 10

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?

Answer 10

Health Insurance Portability and Accountability Act (HIPAA)

Question 11

What was the goal of the Patient Protection and Affordable Care Act signed into law in 2010?

Answer 11

Converting patient records to an electronic format

Question 12

Which of the following is a central component of health information technology (HIT)?

Answer 12

The patient’s medical file

Question 13

Which of the following statements is true regarding the provisions of the Good Samaritan Acts?

Answer 13

The person giving aid owes the stranger a duty of being reasonably careful.

Question 14

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?

Answer 14

Billing for services

Question 15

The Good Samaritan Acts were passed to protect physicians from being charged with which of the following torts?

Answer 15

Negligence

Question 16

In which of the following situations is a physician not expected to obtain consent before proceeding with treatment?

Answer 16

When the physician is acting in an emergency situation.

Question 17

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?

Answer 17

Generally, parental consent is required for a physician to treat a minor with HIV.

Question 18

Technically, abortion is legal in how many states?

Answer 18

50

Question 19

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?

Answer 19

The husband notification requirement

Question 20

Which of the following cases legalized abortion at the Supreme Court level?

Answer 20

Roe v. Wade

Question 21

Which of the following aspects of patient care is the most vital factor to the issue of informed consent?

Answer 21

Patient education

Question 22

Which of the following is an example of a patient who usually cannot give informed consent?

Answer 22

An adult who is mentally incompetent

Question 23

Which of the following information is not usually included in the process of the doctrine of informed consent?

Answer 23

The reputation of the physician performing the procedure

Question 24

The doctrine of informed consent is the legal basis for informed consent. Under which of the following is this doctrine usually outlined?

Answer 24

State medical practice acts

Question 25

For which of the following examples would implied consent not be legally appropriate?

Answer 25

A patient agrees to a test for HIV.

Question 26

Which of the following is an example of implied consent?

Answer 26

A patient makes an appointment for an examination

Question 27

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?

Answer 27

Consent

Question 28

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?

Answer 28

It must state that the information will not be used in court trial

Question 29

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?

Answer 29

Verify the patient’s name, address, and date of birth on the authorization.

Question 30

Which of the following information is the federal statute known as the Confidentiality of Alcohol and Drug Abuse, Patient Records designed to protect?

Answer 30

Patient treatment

Question 31

When a patient medical record is subpoenaed by the court, which of the following information must be listed on the subpoena?

Answer 31

The trial date and time

Question 32

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?

Answer 32

Offer sworn testimony regarding the record if instructed to do so by the court.

Question 33

When a physician is sued for malpractice, whom might the responsibility to comply with a subpoena to produce medical records fall?

Answer 33

The medical office employee

Question 34

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?

Answer 34

Photocopy the medical record and send to the attorney who issued the subpoena.

Question 35

A physician has an obligation to his or her patient based on trust and confidence. What is the term for this obligation

Answer 35

Fiduciary duty

Question 36

In which of the following cases would patient authorization for release of his or her medical record be waived?

Answer 36

When a subpoena duces tecum is issued

Question 37

Which of the following occurs with the medical record when a patient transfers to another physician?

Answer 37

The patient signs an authorization to release his or her records to the new physician

Question 38

Which of the following describes the proper protocol for the release of medical records?

Answer 38

When medical records are subpoenaed, the patient should be notified in writing.

Question 39

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?

Answer 39

2 to 7 years

Question 40

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?

Answer 40

The physician

Question 41

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?

Answer 41

HIPAA

Question 42

The doctrine of professional discretion pertains to medical record keeping. Which of the following does this doctrine occasionally uphold in court?

Answer 42

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

Question 43

A hospital maintains medical records on all patients who are treated. Who owns the information contained in the medical record?

Answer 43

The patient

Question 44

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?

Answer 44

The physician

Question 45

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?

Answer 45

Do not make a change in the record without noting the reason for it.

Question 46

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?

Answer 46

Draw a line through the error so that it is still legible and write above or below the line.

Question 47

Under which of the following circumstances should a separate consent form be obtained to use patient images?

Answer 47

When they will be used for teaching purposes

Question 48

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?

Answer 48

The patient understands that authorization must be given to release photos outside the facility.

Question 49

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?

Answer 49

Invasion of privacy

Question 50

Which of the following should not be included in a patient’s medical record?

Answer 50

Personal judgments

Question 51

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

Answer 51

Nominal

Question 52

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

Answer 52

An award for loss to the patient’s estate of future earnings

Question 53

Which of the following would occur in the pleading phase of a lawsuit?

Answer 53

The defendant’s attorney files an answer to the summons

Question 54

A deposition may be taken in which phase of the lawsuit?

Answer 54

Interrogatory

Question 55

The judge in a lawsuit issues a summons. Which of the following is true about this process

Answer 55

A summons is delivered to the defendant.

Question 56

Which of the following is an example of a pre-trial motion

Answer 56

A defendant may request a change of venue.

Question 57

A set of written questions requiring written answers are given to a plaintiff while under oath. What is the term for this practice

Answer 57

Interrogatory

Question 58

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?

Answer 58

Discovery deposition

Question 59

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?

Answer 59

The objection may be sustained and the witness should not answer the question.

Question 60

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

Answer 60

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

Question 61

Which of the following are recommended guidelines for a health care practitioner who is summoned to appear in court?

Answer 61

Answer the questions asked, no more and no less.

Question 62

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

Answer 62

“As I recall, that is all that occurred in the operating room”

Question 63

A nurse is testifying as a fact witness in a malpractice lawsuit. Which of the following is a recommended guideline for this process?

Answer 63

Answer all questions straightforward, even if answers appear to help opposing side.

Question 64

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

Answer 64

Mediation

Question 65

Alternative dispute resolution has become increasingly popular over the years. What is the reason for this increase in ADR?

Answer 65

Overcrowding of court calendars

Question 66

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?

Answer 66

The court

Question 67

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?

Answer 67

The mediator

Question 68

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?

Answer 68

Consequential-

Question 69

Which of the following examples of negligence would fall under the doctrine of res ipsa loquitur?

Answer 69

A patient suffers an infection caused by the use of unsterilized instruments.-

Question 70

Which of the following is a stated condition for res ipsa loquitur to apply to a lawsuit?

Answer 70

It must be apparent there would be no injury had reasonable care been used-

Question 71

A patient files for negligence under the doctrine res ipsa loquitur. What is the English meaning of this Latin wording?

Answer 71

The thing speaks for itself”-

Question 72

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?

Answer 72

Res ipsa loquitur-

Question 73

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?

Answer 73

Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection-

Question 74

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?

Answer 74

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.-

Question 75

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?

Answer 75

Physicians with expertise in the medical specialty in question-

Question 76

A patient sues a physician for malpractice. Upon whom is the burden of proof for the charge of negligence?

Answer 76

The plaintiff-

Question 77

A health care provider breaches the duty of care to a patient. This element of negligence is defined as:

Answer 77

dereliction.-

Question 78

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?”

Answer 78

Defense-

Question 79

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?

Answer 79

Damages-

Question 80

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?

Answer 80

Duty-

Question 81

Which of the following is an example of misfeasance?

Answer 81

A nurse is changing a patient’s IV line, but does not wash her hands prior to procedure.-

Question 82

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?

Answer 82

Malfeasance-

Question 83

Which of the following is the basis for professional malpractice claims and the most common liability in medicine?

Answer 83

Negligence-

Question 84

In which of the following situations may patient confidentiality be waived?

Answer 84

When a third party requests a medical examination of a person for employment-

Question 85

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?

Answer 85

When on the telephone with a patient, do not use his or her name if others may hear.-

Question 86

In many states, revocation of a physician’s license may occur due to which of the following acts?

Answer 86

Breach of confidence-

Question 87

Which of the following is an example of privileged communication?

Answer 87

A patient tells his physician that he is addicted to pain killers.

Question 88

A nurse recording data in a patient’s medical record maintains confidentiality at all times. Which of the following describes this practice?

Answer 88

Not releasing patient information to unauthorized individuals-

Question 89

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?

Answer 89

They do not establish a doctor-patient relationship.-

Question 90

A physician is a specialist in obstetrics. Which of the following is true regarding the standard of care expected of this physician?

Answer 90

The physician will be held to the same standard of care as other obstetricians.-

Question 91

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?

Answer 91

Negligence-

Question 92

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?

Answer 92

Reasonable person standard-

Question 93

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?

Answer 93

Duty of care-

Question 94

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?

Answer 94

Duty of care-

Question 95

In a hospital setting a certain standard of care is expected of health care practitioners. Which of the following best describes this concept?

Answer 95

An expected level of performance-

Question 96

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?

Answer 96

Employee safety going to and from the work place-

Question 97

A physician who owns a physician’s office is legally responsible for her employees. What is the term for this responsibility?

Answer 97

Liable-

Question 98

medical record

Answer 98

-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)

Question 99

5 “C”s of Charting

Answer 99

1. ) concise
2. ) complete (and objective)
3. ) clear (legible)
4. ) correct
5. ) chronological

Question 100

doctrine of professional discretion

Answer 100

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)

Question 101

fiduciary duty

Answer 101

a physician’s obligation to his or her patient, based on trust and confidence

Question 102

confidentiality of alcohol and drug abuse, patient records

Answer 102

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)

Question 103

consent

Answer 103

permission from a person, expressed or implied, for something to be done by another

Question 104

doctrine of informed consent

Answer 104

legal basis for informed consent, outlined in a state’s medical practice acts
(doctor informs patient of treatment options, risks, etc)

Question 105

able to give informed consent

Answer 105

adults of sound mind, emancipated minors, married minors, mature minors, minors in the military

Question 106

Roe V. Wade

Answer 106

1973. 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.

Question 107

Good Samaritan Acts

Answer 107

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

Question 108

HIT

Answer 108

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)

Question 109

EHR

Answer 109

electronic health record

Question 110

HIPAA

Answer 110

1996. 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. 

Question 111

What are the 5c’s

Answer 111

Concise
Complete (and objective)
Clear (and legibly written)
Correct
Chronologically ordered