39 terms

HIM 115 Ch. 7&8 Review questions

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Who has the legal right to refuse treatment?
Juanita, who is 98 yrs old and of sound mind, Linda, who is 35 incompetent, and created a Living Will prior to becoming incompetent stating that she did not wish to be kept alive artificial mean.
Janice arrives at her physician's office for her 10:30 scheduled appointment and pays her office visit co-payment. Her physician examines her. Based on these facts, Janice's consent is
implied
Mary is contemplating triple bypass surgery. Informed consent by her surgeon would typically contain which of the following
Purpose of proposed procedure, risks assocated wth the procedure, non invasive treatment alternatives
Mary Little is 95 yrs old, While an inpatient at Gen. Hospital, she agrees that she doesnt want to be resuscitated if she would have a cardiopulmonary arrest. She sings a form and the physician documents it in the record. This best describes a
DNR order
An advance directive is used to direct an individual's healthcare wishes in the event of
Patient incapacitation
When a competent adult refuses treatment, a court may be required to balance the individual's privacy interests against
The governments interest in protecting human life
carrying out the wishes stated in a living will applies to whch of the following patient's who is incompetent due to illness?
a 40yr old man who was born with severe mental retardation
Emergences are an exception to the consent requirement for
both adults and minors
The Uniform Health-Care Decisions Act ranks the next of Kin n the following order for medical decision making purposes
spouse; adult child; parent ; adult sibling
Johnny is 12, his parents are divorced. In order for Johnny to receive medical treatment, generally
one parent must consent
Mrs. Baker, who is a competent adult, has consulted her phys. For chronc URQ pain. Her phys. Recommends an elective cholestcystectomy. In this case, who must consent to the operative procedure?
Mrs. Baker
the medical staff at Regency health is nationally revowned for its skill in performing cardac procedures. The nursing staff in the cardiac unit has noticed a signifcant lack of informed consents prior to performance procedures. Obtaining informed consent is the responsiblity of the
Physician
Consent forms that allow for the performance of routine services by healthcare providers are
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.
clear and convincing
What is the primary purpose of patient health information?
patient care
Who is responsible for ensuring the quality of health record documentation?
provider
Which of the following statements about the "legal health record" or the "designated record set" is incorrect?
designated record set is determined by the medical staff
Of the following, which is the most likely to happen to the the health records of a phys. Patient when a phys. Leaves an office practice?
retained by the practice
Once a paper health record has been converted onto microfilm, the info cannot be used as evidence. T/F
False
The legal health record
will be disclosed upon request
The legal health record must meet requirements as defined by the following
federal regulations, state laws, accreditation body standards
Verbal Orders by telephone or in person are discouraged. In cases where verbal orders are necessary, which of the following is the most effective method by which the risk of miscommunication can be lessened?
person receiving the order should read iit back to insure that the order is correct
Which of the following exemplifes an acceptable patient record entry?
patient articulated pain level as a 6
Staff disagreements within the health record should be
avoided
Mrs. Bolton is an angry patient who resents her phys. "bossing her around" refuese to take a portion of the medications that the nurses brng to her pursuant ot phys. Orders., and is verybally abusive to the patient care assistants. Of the following options, the most appropriate way ot document Mrs.Bolton;'s behavior in the medical record is
non compliant and hostile toward staff
legally, whch of the following is the most important in determining the length of time that a hospital must retain medical records?
statute of limitations
Integrity refers to the
accuracy and completeness of information
A goal of E_SIGN legislation was to
give electronic signatures in all business meetings
Auto Authentication
contradicts basic authentication standards
Authentication methods include
handwritten signature, rubber signature stamp, electronic signature
Changes to health record entries
are acceptable in certain circumstances
Printing paper Documents from an HER systems
creates legal challenges as to which document is the source of truth
Which of the following personnel should be authorizes, per hospital policy, to take a physician's verbal order for the administration of medication?
nurse working on the unit where the patient is located
A late entry into the health record should
be identified as a late entry
Abbreviations in the health record
should have only one meaning
The integrity of E H R documentation is more susceptible than the paper health record to which of the following functions?
cut and paste
Record maintenance and contect requirements are established in part by
dept of health and human services, joint commission, centers for medicare and medicaid services
Dr. Harvey has changed a piece of data in a patient record. The info that tracks this change and enables a jury to see this change in a medical malpractice action is called
metadata
Of the following, who has ultimate legal responsibility for the quality of care rendered in a healthcare organization?
governing body