Exam 12: Confidentiality and Compliance

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Explain informed consent. List three ways that a patient can consent to medical treatment.

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Informed consent is the granting of approval for an action by a competent person, of legal age, who is in possession of sufficient information to make a decision.

Which of the following types of files should be separate from the medical records library in a secure file?

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An ____________ is defined as a written document such as a living will or durable power of attorney for health care.

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advance directive

What are the five major categories of HIPAA legislation? What is the difference between the Privacy rule and the Security rule?

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How are security breaches in electronic health records tracked?

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What HIPAA provisions did the HITECH extend? Name and discuss at least two.

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The responsibility for harm or damage caused by actions or inactions is known as:

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A permission that is given after the event to which the permission applies is ___________.

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_________ is consideration of a patient as an adult even though the patient is younger than the statutory age.

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What is jurisdiction? List examples of issues over which municipal, state, and federal courts may have jurisdiction.

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The practice of maintaining confidentiality in health care is based on:

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A _______________ is a facility-wide system of policies, procedures, and guidelines that help to ensure ethical business practices.

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An insurance company may obtain patient records by all of the following EXCEPT:

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Match the following terms with their descriptions.
The person entrusted with the responsibility to care for the confidentiality, privacy, and security of medical records.
Covered entity
Under HIPAA and HITECH provisions, any organization that collects and manages health information.
Conditions of admission
A direction from an officer of the court to provide documents.
Hearsay rule
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Premises:
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The person entrusted with the responsibility to care for the confidentiality, privacy, and security of medical records.
Covered entity
Under HIPAA and HITECH provisions, any organization that collects and manages health information.
Conditions of admission
A direction from an officer of the court to provide documents.
Hearsay rule
An exception to the hearsay rule. It allows health records to be admitted as evidence in legal proceedings because they are kept in the normal course of business, recorded concurrently with the events that they describe, and are recorded by individuals who are in a position to know the facts of the events that are described.
Jurisdiction
The authority of a court to decide certain cases. May be based on geography, money, or type of case.
Subpoena duces tecum
A direction from an officer of the court to provide testimony.
Subpoena ad testificandum
The legal agreement between the health care facility and a patient (or the patient's legal agent) to perform routine services. It may also include the statement of the patient's financial responsibility and prospective consent for release of information and examination and disposal of tissue.
Custodian
The court rule that prohibits most testimony regarding events by parties who were not directly involved in the event.
Business record rule
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An officer of the court's direction to produce documents is called:

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__________ is a permission given by a competent individual, of legal age, with full knowledge or understanding of the risks, potential benefits, and potential consequences of the permission.

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What information is provided when there is a breach of confidential health information? Who is responsible to conduct this investigation?

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The new nursing supervisor is discussing her plans for the unit with you. She wants to hang a board on the wall of the nursing unit listing each patient's name, room number, working diagnosis, and medication schedule. You advise her that:

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Although the __________ owns the physical or electronic record, the _________ owns the information in the record.

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The Conditions of Admission are an example of:

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