CASE STUDY #1
Dr. Roberts, an orthopedic surgeon, and Nurse Parrish, head nurse on the orthopedic surgery unit, have had an acrimonious working relationship for years. While making rounds on the unit, Dr. Roberts discovered that the physical therapy evaluation he had ordered for one of his patients had not been performed and became outraged. Even though he did not have proof, Dr. Roberts placed the blame for the missed evaluation with Nurse Parrish. Dr. Roberts wrote in the patient's medical record that Nurse Parrish failed to properly order the physical therapy evaluation because she was incompetent and could not be trusted to carry out even the simplest order. After having read Dr. Roberts's note, Nurse Parrish countered by making a disparaging remark about Dr. Roberts to the medical personnel at the nurses' station. Nurse Parrish stated that Dr. Roberts was the one who was incompetent and was responsible for the needless suffering of countless patients over the years.
1. Referring to Case Study #1, the written statement by Dr. Roberts about Nurse Parrish's professional competence in the patient's medical record can constitute:
Referring to Case Study #1, the oral statement by Nurse Parrish about Dr. Roberts's professional practices at the nurses' station can constitute:
Referring to Case Study #1, what should Dr. Roberts be reminded of regarding his notation in the patient's chart about Nurse Parrish?
A. It is against the law to mention names of persons who are not actively attending to his patient.
B. His action violates the 1974 Privacy Act.
C. The medical record must not be used as a battleground against another professional.
D. He should erase his note about Nurse Parrish because it is malicious.
Which type of law is constituted by rules and principles determined by legislative bodies?
A. Statutory law
B. Administrative law
C. Common law
D. Case law
Which of the following elements of negligence must be present in order to recover damages?
A. Duty of care; breach of duty of care; value attached to injury is greater than a certain value (ordinarily $1,000); provisions of the HIPAA Privacy Rule have been met
B. Duty of care; breach of the duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000)
C. Duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm
D. Breach of duty of care; suffered an injury; value attached to injury is greater than a certain value (ordinarily $1,000); provision of HIPAA Privacy Rule have been met
When the physician failed to give the patient the lips of the famous actress she requested, the physician engaged in which of the following?
B. A breach of contract
D. Invasion of privacy
Laws that limit the period during which legal action may be brought against another party are known as:
A. case law.
C. statutes of limitations.
D. common law.
The protection of a patient's health information is addressed in each of the following EXCEPT
A. Health Insurance Portability and Accountability Act.
B. Privacy Act.
C. Drug Abuse and Treatment Act.
D. U.S. Patriot Act.
In a court of law, Attorney A, the attorney for Sun City Hospital, introduces the medical record from the hospital as evidence. However, Attorney B, the attorney for the defendant, objects on the grounds that the medical record is subject to the hearsay rule which prohibits its admission as evidence. Attorney B's objection is overridden. Why?
A. The medical record does not belong to the hospital; therefore, the hospital has no right to release the medical record as evidence.
B. It would violate physician-patient privilege, even though the patient signed a proper release of information form.
C. The doctrine of res ipsa loquitur prevails; therefore, reference to the medical record is moot.
D. The medical record may be admitted as business records or as an explicit exception to hearsay rule.
Medical record information may be exempt from the Freedom of Information Act requirements if the request for information meets the test of being an unwarranted invasion of personal privacy.
Which of the following is NOT one of the conditions of the test?
A. The information must be contained in a personal, medical, or similar file.
B. The information is generated from federally funded research conducted by a private health care organization.
C. Disclosure of the information constitutes an invasion of personal privacy.
D. The severity of the invasion must outweigh the public's interest in disclosure.
The doctrine that the decisions of the court should stand as precedents for future guidance is:
A. res ipsa loquitur.
B. respondeat superior.
C. stare decisis.
D. statute of limitations.
The body of law founded on custom, natural justice and reason, and sanctioned by usage and
judicial decision is known as:
A. common law.
C. constitutional law.
B. lien law.
D. statutory law.
CASE STUDY #2
You are the Director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions.
Referring to Case Study #2, Barbara Masters is the _____________ in this case.
Referring to Case Study #2, Bayshore Hospital is the __________________ in this case.
Referring to Case Study #2, the sworn verbal testimony you are asked to provide is called a(n)
C. physical and mental examination.
D. court order.
Referring to Case Study #2, the written answers to questions you have been asked to provide are known as a(n):
C. physical and mental examination.
D. court order.
Referring to Case Study #2, what phase of the lawsuit are you involved in?
A. Pretrial conference
Which of the following claims of negligence fits into the category of res ipsa loquitur?
A. Incorrect administration of anesthesia
B. Failure to refer patient to a specialist
C. Leaving a foreign body inside a patient
D. Improper use of x-rays
The failure to obtain the written consent of the patient before performing a surgical procedure may constitute :
The fee paid for reimbursement for expenses incurred from providing health information whether for subpoena or reproduction by health care providers is determined by the:
A. American Health Information Management Association.
B. hospitals and lawyers.
C. statute or court rules.
D. plaintiff and defendant lawyers.
Who determines the retention period for health records?
A. State and federal governments
B. Medical staff
C. City and state governments
D. Commercial storage vendors
The extent to which the HIPAA privacy rule may regulate an individual's rights of access is not meant to preempt other existing federal laws and regulations. This means that if an individual's rights of access
A. are less under another existing federal law, HIPAA must follow the directions of that law.
B. are refused by a federal facility, HIPAA must also refuse the individual of the access.
C. are greater under another applicable federal law, the individual should be afforded the greater access.
D. are greater under another existing federal law, HIPAA can obstruct freedoms of the other federal law when using electronic health records.
CASE STUDY #3
A 73-year-old male was admitted to the Sunset Nursing Facility with senility, cataracts, and S/P
cerebrovascular accident with right-side hemiplegia. On his second day at the facility, the resident was discovered to have extensive thermal burns on his buttocks and legs by one of the facility's attendants.
Referring to Case Study #3, the resident's family brought legal action against the nursing facility for:
A. medical abandonment.
C. assault and battery.
B. vicarious liability.
Referring to Case Study #3, which of the following can the attorney of the resident's family also use as a basis for the lawsuit and why?
A. The doctrine of res ipsa loquitur because it allows the plaintiff to shift the burden of proof to the defendant because direct evidence is available.
B. The doctrine of charitable immunity because the nursing facility is a private institution and is shielded from liability for any torts committed on its property.
C. The Good Samaritan Statutes because they protect the Director of Nursing, an employee of the nursing facility, who was not present when the injury occurred.
D. The failure to warn theory because the doctor did not inform the resident's family that the resident was in danger at the nursing facility.
In a negligence or malpractice case, all of the following elements must be present in order to shift the burden of proof onto the defendant EXCEPT the :
A. event would not normally have occurred in the absence of negligence.
B. health care facility does not have a risk management program.
C. defendant had exclusive control over the instrumentality that caused the injury.
D. plaintiff did not contribute to the injury.
When a health care facility fails to investigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the health care facility can be held liable under :
A. respondeat superior.
B. corporate negligence.
C. contributory negligence.
D. general negligence.
What source or document is considered the "supreme law of the land"?
A. Bill of Rights
B. Supreme Court decisions
C. presidential power
D. Constitution of the United States
Hospitals that destroy their own medical records must have a policy that:
A. ensures records are destroyed and confidentiality is protected.
B. notifies the physicians when the records of their patients are destroyed.
C. states that all records are destroyed annually.
D. ensures that the type of equipment to be used for destruction of records is properly maintained.
A written authorization from the patient releasing copies of his or her medical records is required by all of the following EXCEPT:
A. the patient's attorney.
B. a physician requesting copies from another physician.
C. an insurance company.
D. the hospital attorney for the facility where the patient is treated.
The medical record is generally accepted as being the property of the:
A. patient's guardian.
The ownership of the information contained in the physical medical/health record is considered to belong to the:
D. insurance company.
When developing a record retention policy, the HIM professionals should consider all of the
A. current storage space.
B. uses of and need for information.
C. all applicable statutes and regulations.
D. the thickness of the records.
If the patient record is involved in litigation and the physician requests to make a change to that record, what should the HIM professional do?
A. Refer request to legal counsel.
B. Allow the change to occur.
C. Notify the patient.
D. Say the record is unavailable.
One of the greatest threats to the confidentiality of health data is:
A. when medical information is reviewed as a part of quality assurance activities.
B. disclosure of information for purposes not authorized in writing by the patient.
C. lack of written authorization by the patient.
D. when medical information is used for research or education.
HIM professionals are bound to protect the confidentiality of patient information under the:
A. Patient Bill of Rights.
B. AHIMA's Code of Ethics.
C. Hippocratic oath.
D. JCAHO standards.
Upon learning that a court order violates state law, the HIM professional should :
A. call the judge issuing the court order.
B. call the opposing attorney.
C. call the legal counsel for the health care institution.
D. ignore the court order.
What type of testimony is inappropriate for a health information manager serving as custodian of the record when he or she is called to be a witness in court?
A. Whether the record is in the practitioner's possession
B. Title and position held in the health care facility
C. Whether the medical record was made in the usual course of business
D. Interpretation of documentation in the record
In order to determine which information should be considered confidential, a health information manager should consider and answer yes to all the following questions EXCEPT:
A. Is there a patient-provider relationship?
B. Is the information needed to treat or diagnose the patient?
C. Was the information in question exchanged through the professional relationship?
D. Is there a need for all health care providers to access the patient information?
Case Study #4
William is a 16-year-old male who lives at home with his parents and works part-time as a dishwasher at one of the local restaurants. While emptying the dishwasher, William is severely scalded and rendered unconscious. He is taken to the emergency room of the local acute care hospital for emergency treatment.
Referring to Case Study #4, given the emergency of the situation, who should the health care provider seek consent from in order to provide treatment to William?
A. The employer
B. The parents
C. The patient
D. No consent is needed for emergency care
Referring to Case Study #4, in order to release information to his employer, the hospital must receive a :
A. consent signed by the patient.
B. court order.
C. consent signed by the doctor.
D. consent signed by the patient's parent.
A valid authorization for the disclosure of health information should not be:
A. dated prior to discharge of the patient.
B. in writing.
C. addressed to the health care provider.
D. signed by the patient.
Internal disclosures of patient information for patient care purposes should be granted:
A. to legal counsel.
B. on a need to know basis.
C. to any physician on staff.
D. to a family member who is an employee.
According to AHIMA's Position on Transmission of Health Information, the health information manager should engage in all of the following to ensure that information is properly sent via facsimile transmission EXCEPT :
A. to always follow up by sending the original record by mail.
B. to preprogram into the machine the number of destination sites.
C. encrypt the data if public channels are used for electronic transmittal.
D. ask the sender to contact the recipient prior to and after transmission.
All of the following need a proper authorization to access a patient's health information EXCEPT:
A. local and state law enforcement officers.
B. IRS agents.
C. medical examiners or coroners.
D. FBI agents.
One best practice to follow in order to establish safeguards for the security and confidentiality of a patient's information when a person makes a request for his or her records in person is to:
A. ask the requester for identification and the request in writing.
B. refuse the request.
C. refer the requester to the facility's attorney.
D. charge an exorbitant fee.
Which of the following acts was passed to stimulate the development of standards to facilitate electronic maintenance and transmission of health information?
A. Health Insurance for the Aged
B. Health Insurance Portability and Accountability Act
C. Conditions of Participation
D. Hospital Survey and Construction Act
The premise that charitable institutions could be held blameless for their negligent acts is known as:
A. doctrine of respondeat superior.
B. doctrine of res ipsa loquitur.
C. doctrine of charitable immunity.
D. negligence factor.
Under traditional rules of evidence, a medical/health record is considered ______________ and is ___________________ into evidence.
A. hearsay; admissible
B. hearsay; inadmissible
C. reliable; admissible
D. reliable; inadmissible
The hospital has a policy that states, "Original medical records may be removed from the Medical Record Department jurisdiction only by court order." Which situation would be a violation of the policy?
A. A physician wishes to have the record sent to the physician lounge in the OR suite for final signatures.
B. The Risk Manger requests the record for review by physicians at a quality assurance meeting.
C. A lawyer has subpoenaed the record for deposition.
D. The physician has been sued and wants to study the original record at home prior to his deposition.
Who is legally responsible for obtaining the patient's informed consent for surgery?
A. The admissions clerk
B. The surgeon performing the surgery
C. The nurse
D. Medical record personnel
With regard to confidentiality, when HIM functions are outsourced (i.e., record copying, microfilming, or transcription), the HIM professional should confirm that the outside contractor's:
A. costs are not prohibitive, thus compromising confidentiality.
B. hours of operation permit easy access by all health care providers.
C. is contractually bound to handle confidential information appropriately.
D. is located in an easy to find place.
A 21-year-old employee of National Services was treated in an acute care hospital for an illness unrelated to work. A representative from the personnel department of National Services calls to request information regarding the employee's diagnosis. What would be the appropriate course of action?
A. Request that the personnel office send an authorization for release of information that is signed and dated by the patient.
B. Require parental consent.
C. Release the information because the employer is paying the patient's bill.
D. Call the patient to obtain verbal permission.
Darling v. Charleston Community Memorial Hospital is considered one of the benchmark cases in health care because it was with this case that the doctrine of _______________ was eliminated for nonprofit hospitals.
A. charitable immunity
B. corporate negligence
C. professional negligence
D. contributory negligence
All of the following are elements of a contract EXCEPT :
A valid authorization for release of information contains:
A. the name, agency, or institution to which the information is to be provided.
B. the name of the hospital or provider who is releasing the medical information.
C. the date and signature of the patient or the patient's authorized representative.
D. all of the above.
In which of the following circumstances would release of information without the patient's authorization be permissible?
A. Release to an attorney
B. Release to third-party payers
C. Release to state workers' compensation agencies
D. Release to insurance companies
Who decides whether all or portions of the medical record will be received in evidence in a court of law?
A. Presiding judge/court
B. Subpoenaing attorney
C. Clerk of the court
Which of the following health care systems have to comply with the requirements of the Freedom of Information Act?
A. Private hospitals
B. Physicians' offices
C. Veteran's hospitals
D. Single day surgery clinics
Which of the following measures should a health care facility incorporate into its institution-wide security plan to protect the confidentiality of the patient record?
A. Verification of employee identification
B. Locked access to data processing and record areas
C. Use unique computer passwords, key cares, or biometric identification
D. All of the above
A signed consent for release of information dated December 1, 2010 is received with a request for the chart from the patient's admission of 12/5/2010. Indicate the appropriate response from the options below.
A. Request another authorization that is dated closer, but prior to, the admission date.
B. Request another authorization dated after the discharge date.
C. Release the requested information.
D. Call the patient for a verbal authorization.
Willful disregard of a subpoena is considered:
A. breach of contract.
B. abuse of process.
C. contributory negligence.
D. contempt of court.
HIM personnel charged with the responsibility of bringing a medical record to court would ordinarily do so in answer to a:
A. personal subpoena.
C. subpoena duces tecum.
HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets forth all of the following EXCEPT:
A. covered entities provide every patient with its annual business report.
B. how covered entities may use and disclose PHI.
C. patient's rights regarding the covered entities' uses and disclosures.
D. covered entities' obligations for protecting the patient's PHI.
A record that has been requested by subpoena duces tecum is currently located at an off-site microfilm company. By contacting the microfilm provider, you learn that the microfilm is ready and the original copy of the record still exists. What legal requirement would compel you to produce the original record for the court?
A. Best evidence rule
B. Hearsay rule
C. Motion to quash
D. Subpoena instanter
Which resource is the most valuable to monitor Medicare changes?
A. Journal of AHIMA
B. HIM peers
C. Federal Register
D. Medical Records Briefing
As a general rule, a person making a report in good faith and under statutory command (e.g., on child abuse, communicable diseases, births, deaths, etc.) is:
A. not protected from liability claims.
B. subject to penalties imposed by federal law.
C. subject to penalties imposed by state law.
According to AHIMA and AHA guidelines, which of the following would be an acceptable authorization for release of information from the medical record of an adult, mentally competent patient hospitalized from 4/16/2010 to 5/10/2010? An authorization dated :
A. 7/10/2010 and presented 7/15/2010
B. 5/09/2010 and presented 1/15/2011
C. 3/10/2010 and presented 5/15/2010
D. 2/15/2010 and presented 1/10/2011
Which would be the better "best practice" for handling fax transmission of a physician's orders?
A. Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required time period.
B. Faxed orders should be placed on the patient's chart immediately upon receipt after the head nurse signs the orders.
C. Wait 24 hours before placing faxed orders on the patient's chart to ensure that the orders are legitimate.
D. Faxed orders should never be accepted.
The Darling v. Charleston Community Memorial Hospital case established the following doctrine for hospitals to observe and changed the way hospitals dealt with liability.
A. Doctrine of respondeat superior
B. Doctrine of continuing wrong
C. Doctrine of res ipsa loiter
D. Doctrine of corporate negligence
HIM professionals have a duty to maintain health information that complies with :
A. state statutes.
B. federal statutes.
C. accreditation standards.
D. all of the above.
In general, which of the following statements is correct?
A. When federal and state laws conflict, valid federal laws supersede state laws.
B. When federal and state laws conflict, valid state laws supersede federal laws.
C. When federal and state laws conflict, valid local laws supersede federal and state laws.
D. When federal and state laws conflict, valid corporate policies supersede federal and state laws.
Which of the following statements is correct regarding HIPAA preemption analysis?
A. If the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the state law prevails.
B. State law regarding a patient's right to health care information privacy can never prevail over the HIPAA federal rule.
C. If a state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, then the courts must decide which shall prevail.
D. Even if the state law that recognizes a patient's right to health care information privacy is more stringent than the HIPAA federal rule, the HIPAA federal rule will still prevail.
The minimum record retention period for patients who are minors is:
A. age of majority.
B. age of majority plus the statute of limitations.
C. 5 years past treatment.
D. 2 years past treatment.
In which type of facility the Privacy Act of 1974 permits patients to request amendments to their medical record?
A. Private proprietary health care facility
B. Mental health and chemical dependency facility
C. University-based teaching facility
D. Department of Defense health care facility
What advice should be given to a physician who has just informed you that she just discovered that a significant portion of a discharge summary she dictated last month was left out?
A. Squeeze in the information omitted by writing in available spaces such as the top, bottom, and side margins.
B. Dictate the portion omitted with the heading "Discharge Summary—Addendum" and make a reference to the addendum with a note that is dated and signed on the initial Discharge Summary (e.g., "9/1/08—See Addendum to Discharge Summary"—Signature).
C. Redictate the discharge summary and replace the old one with the new one.
D. Inform the physician that nothing can be done about the situation.
While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation?
A. Remove the incident report and send it to the patient.
B. Tell the employee to leave the report in the record.
C. Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record.
D. Refer this record to the Risk Manager for further review and removal of the incident report.
Which of the following is considered confidential information if the patient is seeking treatment in a substance abuse facility?
A. Patient's name
B. Patient's address
C. Patient's diagnosis
D. All of the above
In electronic health records, authentication may be achieved by:
A. handwritten signature.
B. digital signature.
C. verbal statement.
D. all the above.
It is common practice to forgo patient authorization for the release of information when the:
A. patient is an employee.
B. patient is a physician.
C. patient has a direct transfer from the hospital to a long-term care facility.
D. patient is incompetent.
Many states have recognized a minor's right to seek treatment without parental consent in all of the following situations EXCEPT a(n) :
A. minor seeking treatment for breast reduction.
B. minor seeking treatment for a sexually transmitted disease.
C. minor seeking treatment for alcohol and substance abuse.
D. emancipated minor seeking treatment for breast enlargement.
When a record custodian brings the medical record to court in response to a subpoena duces tecum, it is her responsibility to:
A. identify the record in her official capacity as custodian.
B. present the case favorably for the patient involved.
C. leave the original record in the possession of the plaintiff's attorney.
D. explain details of the medical treatment given to the patient.
When substituting a photocopy of the original record in response to legal process, which of the following can be helpful in convincing the court to accept the photocopy as a true and exact copy of the original?
A. Certificate of authentication
B. Consent from the patient
C. Consent from the hospital administrator
D. Correspondence from the attending physician
Which of the following should be required to sign a confidentiality statement before having access to patients' medical information?
A. Nursing students
B. Medical students
C. HIM students
D. All of the above
All of the following have laws and regulations addressing medical records EXCEPT:
A. accrediting agencies.
B. corporate law.
C. state laws.
D. federal laws.
The proper method for correcting a documentation error in a medical record is for the author to:
A. draw an "X" through the incorrect documentation.
B. draw a single line through the incorrect information, date and initial the change.
C. white it out, date and initial the change.
D. remove the form from the chart and add a revised form.
All of the following are sources for the rules and regulations that define the legal aspects of
medical records EXCEPT:
A. institutional policies.
D. regulations, governmental and nongovernmental.
To be admitted into court as evidence, medical records or health information are introduced as:
A. torts or contracts.
B. privileged information.
C. records or exceptions to hearsay rule.
D. product liability.
A health care organization's compliance plans should not only focus on regulatory compliance, but also have a :
A. strong personnel component that reduces the rapid turnover of nursing personnel.
B. coding compliance program that prevents fraudulent coding and billing.
C. component that increases the security of medical records.
D. substantial program that increases the availability of clinical data.
A written consent from the patient is required from which of the following entities in order to learn a patient's HIV status?
A. Insurance companies
B. Emergency medical personnel
C. Spouse or needle partner
D. Health care workers
The Uniform Business Records as Evidence Act addresses:
A. medical records maintained on health care workers.
B. insurance documents.
C. medical and lab reports in health care facilities.
D. admissibility of record reproductions
The ideal consent for medical treatment obtained by the physician is:
Which of the following is an example of the breach of confidentiality?
A. A nurse speaking with the physician in the patient's room
B. Staff members discussing patients in the elevator
C. The admission clerk verifying over the phone that the patient is in-house
D. The hospital operator paging code blue in room 3 north
Which of the following would be an inappropriate procedure for the custodian of the medical record to perform prior to taking a medical record from a health care facility to court?
A. Number each page of the record in ink.
B. Document in the file folder the total number of pages in the record.
C. Remove any information that might prove detrimental to the hospital or physician.
D. Prepare an itemized list of sheets contained in the medical record.
Which of the following agencies is empowered to implement the law governing Medicare and Medicaid?
A. Centers for Medicare and Medicaid Services (CMS) formerly known as Health Care
Financing Administration (HCFA)
B. Joint Commission
C. Institutes of Health
D. Department of Health and Human Services
Consent forms may be challenged on all the following grounds EXCEPT:
A. wording was too technical.
B. the treating physician obtained the patient's signature.
C. it is written in a language that the patient could not understand.
D. the signature was not voluntary.
Mandatory reporting requirements for vital statistics generally:
A. do not require authorization by the patient.
B. require authorization by the physician.
C. require authorization by the payer.
D. do not apply to health care facilities.
The responsibility of obtaining an informed consent for a surgical or invasive procedure rests with the:
Courts have released adoption records based upon:
A. the request of the adoptee.
B. the request of the biological parent(s).
C. the Freedom of Information Act.
D. a court order for good cause.
The legislation that required all federally funded facilities to inform patients of their rights under state law to accept or refuse medical treatment is known as:
A. advance directives.
B. living wills.
C. Patient Self-Determination Act.
D. durable power of attorney.