Test 3 Flashcards
A living will ________.
a. Enables another to make healthcare decisions for an individual
b. Is written when an individual is alive, but applies when the individual dies
c. Always takes precedence over a durable power of attorney for healthcare if both exist
d. Expresses an individual’s healthcare wishes when specific health conditions exist
Expresses an individual’s healthcare wishes when specific health conditions exist
Mr. Smith fell off his roof while cleaning the gutters on his home and is brought into the ER comatose. He does not have the capacity to communicate consent to his treatment, thus________________.
a. The staff cannot treat him
b. His consent is expressed so he can be treated by the ER staff
c. His consent is implied by law, so ER staff can treat him
d. None of the above
His consent is implied by law, so ER staff can treat him
Emancipated minors are defined as those who have____________.
a. Reached age 17
b. Gotten married
c. Disowned their parents
d. Been afforded legal status as an adult
Been afforded legal status as an adult
Informed consent requires informing the patient of all of the following except______.
a. Nature and purpose of proposed treatment
b. Risks and benefits of proposed treatment
c. Alternatives to proposed treatment
d. Hospital charges versus amount covered by insurance
Hospital charges versus amount covered by insurance
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_________.
a. Probable cause
b. Preponderance of the evidence
c. Proof beyond a reasonable doubt
d. Clear and convincing evidence
Clear and convincing evidence
Laws that require drivers to consent to blood alcohol tests, with penalties for refusal, exist to___________.
a. Harass citizens
b. Promote business for medical facilities
c. Protect the public
d. None of the options are correct
Protect the public
Under the Common Rule, informed consent for human subjects in research studies may be waived if__________.
a. Obtaining consent will take too much time
b. Obtaining consent will be too costly
c. The human subjects agree to a waiver
d. The IRB approves a waiver
The IRB approves a waiver
A do-not-resuscitate order________.
a. Is a type of advance directive
b. Is used only in emergency situations
c. May be revoked at any time
d. All of the options are correct
All of the options are correct
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 _____________
a. The physician’s interest in saving lives
b. The government’s interest in collecting taxes from living individuals
c. The government’s interest in protecting and preserving human life
d. The physician’s interest in persuading a patient to seek and pay for treatment
The government’s interest in protecting and preserving human life
The Uniform Health-Care Decisions Act (UHCDA)__________.
a. Provides no legal immunity to providers
b. Provides an additional option to creating advance directives
c. Negates the effect of advance directives, even if they comply with the UHCDA
d. Does not allow a surrogate to be appointed in the absence of an advance directive
e. Provides no legal immunity to providers
Provides an additional option to creating advance directives
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?
a. The person receiving the order should read it back to ensure that the order is correct.
b. The order should be signed after the patient is discharged from the facility.
c. The order should be signed by another provider.
d. The person receiving the order should authenticate the order after it is entered into the record.
The person receiving the order should read it back to ensure that the order is correct.
Frances, a nurse at a long-term care facility, has had a very busy day. She has not been able to write some of her entries into the paper-based records until the end of her shift. Frances knows that late entries should _________.
a. Be identified as a late entry
b. Not be permitted
c. Not be documented more than 24 hours after the event
d. Be inserted into the space for the date and time written about
Be identified as a late entry
Abbreviations in the health record_________.
a. Are not permitted by Joint Commission standards
b. Should have only one meaning
c. Enhance patient safety
d. Are critical to an electronic health record system
Should have only one meaning
The integrity of EHR documentation is more susceptible than the paper health record to which of the following functions?
a. Use of abbreviations
b. Illegibility
c. Cut and paste
d. All of the above
Cut and paste
Of the following, who has ultimate legal responsibility for the quality of care rendered in a healthcare organization?
a. Governing body
b. Medical staff
c. Administration
d. Providers
Governing body
Which Act served to make electronic transactions as enforceable as paper transactions?
a. Patient Self-Determination Act
b. Uniform Electronic Transactions Act
c. Health Care Quality Improvement Act
d. Best Evidence Rule
Uniform Electronic Transactions Act
A countersignature__________.
a. Indicates a disagreement between two individuals who sign an entry
b. Signifies review and evaluation of the first provider’s entry
c. Is required by the Joint Commission for all health record entries
d. None of the above
Signifies review and evaluation of the first provider’s entry
A goal of E-SIGN legislation was to __________.
a. Minimize the use of electronic signatures in healthcare
b. Mandate the use of electronic signatures in all business settings
c. Give electronic signatures increased legal standing
d. None of the above
Give electronic signatures increased legal standing
In general, the Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) does which of the following?
a. Does not allow health records to be photocopied
b. Allows record reproductions to be admitted as evidence
c. States that health records are public records
d. Allows a jury to review copied records, but not original records
Allows record reproductions to be admitted as evidence
Destruction of health records __________.
a. May be a prudent business practice
b. Is discouraged by AHIMA record retention guidelines
c. Is prohibited by HIPAA
d. Is required by Medicare
May be a prudent business practice
Kimberly has just completed an appointment with her physician. The physician told Kimberly about her medical condition and explained the preferred treatment options to her. It was the physician’s expectation that Kimberly would follow his recommendations. This situation describes what type of relationship?
a. Paternalistic
b. Interopretive
c. Informative
d. Mutual
Paternalistic
The community benefit standard_________.
a. Is required for tax-exempt status
b. Requires hospitals to accommodate all languages spoken by patients in a community
c. Requires hospitals to provide uncompensated care to 50 percent of its elective patients
d. Ensures that healthcare providers do not violate the Civil Rights Act of 1964
Is required for tax-exempt status
The EMTALA regulations include all but which of the following?
a. Every patient arriving at the emergency department must recieve an appropriate medical screening exam
b. Transfer of non-stabiilized patients must only occur under certain specific conditions
c. If an emergency medical condition exists, the hospital must treat and stabilze the emergency condition or transfer the patient
d. Non-Medicare, indigent patients must be transferred to the nearest Level 1 trauma center.
Non-Medicare, indigent patients must be transferred to the nearest Level 1 trauma center.
The Hill-Burton Act _________.
a. Was passed by Congress in 2000
b. Decreased the obligation to provide uncompensated care
c. Provided hospitals with money for construction of modernization
d. Exempts hospitals from complying with EMTALA
Provided hospitals with money for construction of modernization
With regard to seclusion and restraint, federal laws
a. Prohibit their use
b. Encourage their use
c. Restrict their use
d. None of the above
Restrict their use
What is the role of a billing advocate?
a. Ensure the hospitals are paid the highest amount possible by health insurers
b. Insist that patients pay their health insurance companies
c. Prompt patients to pay their health insurance premiums in a timely manner
d. Negotiate with providers to lower bills for patients unable to pay in full
Negotiate with providers to lower bills for patients unable to pay in full
Cultural competence takes into account_________.
a. Religion
b. Gender identity
c. Ethnicity
d. All of the above
All of the above
Sally uses a patient health information portal.
a. It limits Sally’s access to her physician because it serves as a replacement
b. It lessens her access to her health information because she can no longer access her full medical record
c. It increases price transparency
d. It increases her 24/7 access to her health information
It increases her 24/7 access to her health information
Against medical advice” discharges_________.
a. Are legally prohibited
b. Are associated with poor outcomes and higher readmission and mortality rates
c. Do not require a protocol because the action is initiated by the patient, not the provider
d. May result, if granted, in a battery claim against the healthcare provider
Are associated with poor outcomes and higher readmission and mortality rates
Which of the following is not a HIPAA individual right?
a. Make changes to PHI/Request restrictions regarding PHI use and disclosure for treatment
b. Request accounting of disclosure/Import PHI content into the provider’s health record
c. Access to PHI
d. Request amendments to PHI
Make changes to PHI/Request restrictions regarding PHI use and disclosure for treatment
Consent that is conveyed through spoken or written words is______.
a. Implied
b. Informed
c. Express
d. Unilateral
Express
If a proposed medical intervention is related to a research study _______.
a. Consent is not required
b. Institutional review board approval is required
c. Consent is only required if the risk of death is significant
d. Consent is only required if there is a risk the patient will bet drop out
Institutional review board approval is required
If it is not durable, a power of attorney (POA) is effective_________.
a. Only when the principal has capacity
b. Only when the principal is mentally incompetent
c. Only when the principal is not in control of themselves
d. Only when the principal has capacity and is mentally incompetent
Only when the principal has capacity
A physician who performs a surgical procedure on a patient without obtaining the patient’s consent may be liable for________.
a. Assault
b. Battery
c. Nonfeasance
d. Negligence
Battery
Carrying out the wishes stated in a living will applies to which of the following patients, who is incompetent due to an illness?
a. ) A 14-year-old girl
b. ) A 40-year-old man who was born with severe mental retardation
c. ) A 63-year-old woman who talked about creating an Advance Directive, but never did
d. ) A 90-year-old man who created an advance directive while he was competent
A 90-year-old man who created an advance directive while he was competent
Kathleen completes a valid Durable Power of Attorney for Healthcare Decisions authorizing her husband, Bill, to make healthcare decisions for her in the event she should become mentally incompetent. In this situation __________.
a. ) Kathleen is the principal and agent
b. ) Bill is the principal principle and agent
c. ) Kathleen is the principal and Bill is the agent
d. ) Bill is the principal
Kathleen is the principal and Bill is the agent
The Patient Self-Determination Act requires healthcare providers to __________.
a. ) Inform patients of their right to create advance directives
b. ) Document the presence or absence of an advance directive in a patient’s health record
c. ) Educate staff and community about advance directives
d. ) All options are correct
All options are correct
Mrs. Davis is preparing to undergo hernia repair surgery at Deaconess Hospital. Who is responsible for obtaining Mrs. Davis’s consent for this procedure?
a. ) The surgeon should obtain Mrs. Davis’ informed consent.
b. ) Informed consent is not necessary because this is not major surgery.
c. ) An employee from the hospital’s surgery department should obtain Mrs. Davis’ informed consent.
d. ) It does not matter who obtains Mrs. Davis’ informed consent as long as it is documented in her medical record.
The surgeon should obtain Mrs. Davis’ informed consent.
An advance directive is used to direct an individual’s healthcare wishes in the event of __________.
a. ) Patient incapacitation
b. ) Patient indecisiveness
c. ) Patient’s ability to pay healthcare bill
d. ) A disagreement between patient and family
Patient incapacitation
When a competent adult refuses treatment, a court may be required to balance the individual’s privacy interests against __________.
a. ) The patient’s level of pain
b. ) The physician’s right to keep the patient alive
c. ) The provider’s liability concerns
d. ) The government’s interest in protecting human life
The government’s interest in protecting human life
Mary is contemplating triple bypass surgery. Informed consent by her surgeon would typically contain which of the following elements?
a. ) Purpose of proposed procedure
b. ) Risks associated with the procedure
c. ) Non-invasive treatment alternatives
d. ) All of the options are correct
All of the options are correct
Johnny is 12 and his parents are divorced. He is living with his father, who has legal custody of Johnny. In order for Johnny to receive medical treatment, generally, __________.
a. ) Both of Johnny’s parents must consent
b. ) Johnny’s father as parent with legal custody would consent
c. ) A court-appointed guardian must consent
d. ) Johnny can consent
Johnny’s father as parent with legal custody would consent
Alison, who is a competent adult, has consulted her physician for chronic right upper quadrant pain. Her physician recommends an elective cholecystectomy. In this case, who must consent to the operative procedure?
a. ) Alison
b. ) Alison and her husband
c. ) Alison’s husband
d. ) Alison’s legal guardian
Alison
Emergencies are an exception to the consent requirement for __________.
a. ) Incapacitated adults
b. ) Married minors
c. ) Competent adults
d. ) All options are correct
All options are correct
The medical staff at Regency Health is nationally renowned for its skill in performing cardiac procedures. The nursing staff in the cardiac unit has noticed a significant lack of informed consents prior to the performance of certain procedures. Administration at the facility should reinforce that __________.
a. ) The nursing staff obtain informed consents
b. ) The admissions department obtain the informed consents
c. ) The physician responsible for the procedure obtain informed consent
d. ) The health information management department obtain informed consent
The physician responsible for the procedure obtain informed consent
Consent forms that allow for the performance of routine services by healthcare providers are __________.
a. ) General consents
b. ) Informed consents
c. ) Long consents
d. ) Human subjects research consents
General consents
In the Cruzan case, the court held that a person cannot assume end-of-life decisions on behalf of an incompetent person without _________ evidence that the person would refuse the continuation of life-sustaining treatment.
a. ) Probable cause
b. ) beyond a reasonable doubt
c. ) preponderance of evidence
d. ) clear and convincing
clear and convincing
If an individual consents to treatment, but later alleges that she was not fully informed of the risks, benefits and alternatives, what legal claim is most appropriate?
a. ) Battery
b. ) Negligence
c. ) Proximate cause
d. ) Misfeasance
Negligence
For which of the following conditions would a minor most likely be able to consent to treatment on his own behalf?
a. ) Leukemia
b. ) Dislocated shoulder
c. ) Sexually transmitted disease
d. ) Concussion
Sexually transmitted disease
Mary Jackson is 95 years old. While an inpatient at General Hospital, she agrees that she does not want to be resuscitated if she would have a cardiopulmonary arrest. She signs a form and the physician documents it in the record. This best describes a(an) __________
a. ) Living will
b. ) Durable Power Attorney for Healthcare Decisions
c. ) DNR order
d. ) Illegal activity
DNR order
When a physician or other healthcare professional renders care to another individual at a scene of an accident, the healthcare provider is usually not held liable for civil damages for acts or omissions of rendering care based on what form of state statue?
a. ) Good Samaritan statue
b. ) Implied consent statue
c. ) DNR statue
d. ) Uniform Health-Care Decision statue
Good Samaritan statue
Which of the following statement are true regarding informed consents?
a. ) The Joint Commission requires that informed consent be placed in the patient record
b. ) The AMA suggests physicians disclose alternatives to the treatment they are offering
c. ) CMS requires the presence of a signed consent form in the patient’s record
d. ) All options are correct
All options are correct
The legal health record ___________.
a. Is inadmissible into evidence
b. Is the record that is disclosed upon request
c. May not be hybrid
d. Must consist in part of paper
Is the record that is disclosed upon request
Jill has been asked to revise the health record retention policy for her organization. In particular, administration believes the current policy does not properly reflect the length of times that the records of minors should be retained. In conducting her research, Jill refers to the AHIMA best practices for record retention. Based on what she has researched, which of the following should she recommend to administration regarding retention of the health records of minors?
a. 10 years plus statute of limitations
b. 20 years plus statute of limitations
c. Age of majority plus statute of limitations
d. Do not address them separately; they should conform to the same rentention period as all other records in the organization
Age of majority plus statute of limitations
The legal health record must meet standards as defined by the following:
a. State laws,
b. Federal regulations,
c. Accreditation body standards
d. All of the above
All of the above
Which of the following personnel should be authorized, per hospital policy, to take a physician’s verbal order for the administration of medication?
a. Unit secretary working on the unit where the patient is located
b. Nurse working on the unit where the patient is located
c, All of the above
d. None of the above, Joint Commission prohibits verbal orders
Nurse working on the unit where the patient is located
When comparing the HIPAA-defined designated record set with the legal health record, which of the following is correct?
a. The designated record set is wider in scope than the legal health record.
b. The designated record set is narrower in scope than the legal health record
c. The legal health record includes billing and insurance enrollment documents
d. All elements of the designated record set must be included in the legal health record
The designated record set is wider in scope than the legal health record.
Dr. Harvey has changed a piece of data in a patient record. The information that tracks this change and enables a jury to see this change in a medical malpractice action is called
a. Volume
b. Metadata
c. Persistance
d. Evidence
Metadata
Which of the following are factors that influence health record retention periods?
a. Federal and state laws
b. Costs of retention
c. Statutes of limitations
d. All of the above
All of the above
Which of the following is not a purpose of the health record?
a. Serve as a legal document
b. Provide proof of services for reimbursement,
c. Serve as a communication tool among providers
d. All of the are purposes of health record
All of the are purposes of health record
The Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) __________.
a. Discourages the use of record reproductions
b. Supports the admissibility of reproductions into evidence with stipulations
c. Inhibits the transition from paper to electronic storage of information
d. Allows the admssability of reproductions into evidence in all legal cases
Supports the admissibility of reproductions into evidence with stipulations
If two healthcare professionals disagree about the course of treatment for a patient, how should this be documented in the health record?
a. Both professionals should record their opinions in the record independently of the other
b. Each professional should point out the error of the other professional’s opinion
c. Neither professional should mention the patiient’s course of treatment in the record, so as to avoid liability
d. Objective terms such as “mistaken” and “negligent” should be used by each professional to describe the other professional’s opinion
Both professionals should record their opinions in the record independently of the other
Integrity refers to the __________.
a. Source or origin of information
b. Accuracy and completeness of information
c. Timeless and completeness
d. Co-signature of the attending physician
Accuracy and completeness of information
Authenticity pertains to the _______.
a. Original copy of a record
b. Genuineness of a record
c. Signatures of entries within a record
d. Completness of the information in a record
Genuineness of a record
An error in a paper health record should be __________.
a. Whited out so its content is not relied on
b. Obliterated with ink so its content is not relied on
c. Left intact so there will be no question about what it said
d. Crossed out so that it can be seen but not relied on
Crossed out so that it can be seen but not relied on
Which of the following is true of health record destruction?
a. It is prohibited because every piece of health information must be kept forever
b. It is permitted pursuant to an approved retention schedule and destruction policy
c. It is encouraged if a health record is involved in litigation
d. None of the above
It is permitted pursuant to an approved retention schedule and destruction policy
When ownership of a physician practice changes, __________.
a. The health records of the original physician must be destroyed
b. The health records of the practice may be transferred as assets
c. Patients have no right to their health records
d. None of the above
The health records of the practice may be transferred as assets
Which of the following should be included in the definition of the legal health record?
a. Incidents reports
b. Insurance forms
c. Cancer registry data
d. History and physical
History and physical
In its record retention schedule, AHIMA recommends that the master patient index be retained ________.
a. 10 years
b. 20 years
c. Permanently
d. No period is specified for these records
Permanently
At Frank’s recent medical appointment, his physician provided information to Frank, but Frank made his own treatment decisions. This situation describes what type of relationship?
a. Informative
b. Paternalistic
c. Interpretive
d. Mutual
Informative
Eleanor has refused life-saving treatment. Which of the following is true?
a. Eleanor has the right of self-determination to refuse treatment
b. The hospital may not refer this decision to a court
c. Eleanor does not have the right to refuse treatment
d. Her refusal is voided because it will result in her death
Eleanor has the right of self-determination to refuse treatment
The American Hospital Association’s Patient Bill of Rights became the____.
a. Quality Healthcare Initative
b. Patient Care Partnership
c. Quality improvement organization
d. Joint commission sentiinel event
Patient Care Partnership
The Hill-Burton Act is significant because it did which of the following?
a. Strengthened EMTALA legislation
b. Created the Medicare program
c. Elimated discrimination in healthcare
d. Funded hospital construction and modernization
Funded hospital construction and modernization
Medicare requirements pertaining to seclusion and restraint___.
a. Encourage their use through flexible standards
b. Restrict their use
c. Prohibits seclusion for patients less than 18 years old
d. Prohibits restraint for patients less than 18 years old
Restrict their use
Teresa is a billing advocate. NetHealth is an insurance company. StarServe is a provider. Bob is a patient. Which of the following roles will Teresa serve?
a. Making sure that Bob pays the starserve bill in a tiimely manner
b. Negotiating with hospitals on behalf of Nethealth to obtain original rates
c. Negotiating with StarServe to lower Bob’s medical bills
d. Making sure that Bob pays his Nethealth premiums in a timely manner
Negotiating with StarServe to lower Bob’s medical bills
What is an effect of Christy’s access to a patient health information portal?
a. She has less access to her full medical record as a result
b. It decreases price transparency for Christy
c. It limits Christy’s ability to access her physician because it serves as a replacement
d. It provides her with increased, timely access to her health information
It provides her with increased, timely access to her health information
With respect to patient rights, the Joint Commission standards:
a. Do not address patient rights
b. Contain a provision regarding the review of patient complaints
c. Address patient rights in most contexts, but do not address research and clinical trials
d. Mendate the actual language to be used in patient rights policies
Contain a provision regarding the review of patient complaints
The patient’s right to the confidentiality of his or her health information is reinforced through_________.
a. All of the above
b. Medicare Conditions of Participation
c. Accreditation standards
d. Professional best practices
All of the above
The most widely-used feature provided by patient health information portals is_________.
a. Online scheduling
b. The ability to copy medical records onto paper
c. Viewing test results
d. Exchanging secure messages with providers
Viewing test results
Health literacy focuses on_________.
a. All of the above
b. Individuals for whom English is a second language
c. Individuals with limited reading proficiency
d. Varying levels of technological proficiency
All of the above
At its most basic level, patient rights addresses_________.
a. The ability of patients to make their own healthcare decisions
b. Desired clinical outcomes
c. Conduct between a healthcare provider and a patient
Conduct between a healthcare provider and a patient
The patient-provider relationship that involves shared decision-making is_________.
a. Informative
b. Paternalistic
c. Individualistic
d. Interpretive
Interpretive
EMTALA was passed in response to the problem of_________.
a. Patient dumping
b. Inflated healthcare costs
c. Low-quality medical care
d. Poor patient-provider communication
Patient dumping
Which of the following should occur when a patient leaves a hospital against medical advice?
a. All of the above
b. Patient signs a form acknowledging potential consequences
c. Patient signs a form acknowledging health insurance may refuse to pay for care provided
d. Risks are discussed with the patient when possible
e. Documentation of the AMA in the patient’s medical record
All of the above
