Question 1

List the five C's that describe the attributes of a good entry into the medical record.

Accepted Answer

Entries in a patient record must be concise, complete and objective, clear and legibly written, correct, and chronologically ordered. They should never contain inappropriate judgments or observations or attempts at humor.

Question 2

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

Accepted Answer

A)  prevention of medical errors 
B)  reduction of health care costs 
C)  decreased paperwork 
D)  less improvement in health care quality 
E)  early detection of infectious outbreaks around the country 
A)  prevention of medical errors 
B)  reduction of health care costs 
C)  decreased paperwork 
D)  less improvement in health care quality 
E)  early detection of infectious outbreaks around the country E

Question 3

Medical records should be kept until the applicable statute of limitations period has elapsed. What is the usual timeframe for this period of time?

Accepted Answer

A)  1 to 3 years 
B)  1 to 5 years 
C)  2 to 10 years 
D)  2 to 7 years 
E)  3 to 20 years 
A)  1 to 3 years 
B)  1 to 5 years 
C)  2 to 10 years 
D)  2 to 7 years 
E)  3 to 20 years D

Question 4

Which of the following is not a best practice guideline for maintaining confidentiality?

Accepted Answer

A)  Discard faxed copies in the recycle bin. 
B)  Verify fax telephone numbers before sending. 
C)  Use a fax cover sheet that states "Confidential: to addressee only." 
D)  Do not leave a computer monitor unattended while confidential information is displayed. 
E)  Print confidential information to specific printers that are not in general use. 
A)  Discard faxed copies in the recycle bin. 
B)  Verify fax telephone numbers before sending. 
C)  Use a fax cover sheet that states "Confidential: to addressee only." 
D)  Do not leave a computer monitor unattended while confidential information is displayed. 
E)  Print confidential information to specific printers that are not in general use.

Question 5

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

Accepted Answer

A)  for an insurance claim 
B)  for medical injuries sustained in an auto accident 
C)  when a subpoena duces tecum is issued 
D)  when a patient dies 
E)  when transferring to another physician 
A)  for an insurance claim 
B)  for medical injuries sustained in an auto accident 
C)  when a subpoena duces tecum is issued 
D)  when a patient dies 
E)  when transferring to another physician

Question 6

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

Accepted Answer

A)  the treating physician 
B)  the patient 
C)  the hospital 
D)  the insurance company paying the bills 
E)  the surgeon 
A)  the treating physician 
B)  the patient 
C)  the hospital 
D)  the insurance company paying the bills 
E)  the surgeon

Question 7

Medical records are:

Accepted Answer

A)  legal documents 
B)  not legal documents if kept electronically 
C)  always the property of the patient 
D)  never the property of the patient 
E)  legal documents only when a subpoena has been issued 
A)  legal documents 
B)  not legal documents if kept electronically 
C)  always the property of the patient 
D)  never the property of the patient 
E)  legal documents only when a subpoena has been issued

Question 8

To correct an error discovered after the patient's written copy of his or her medical records has been recorded, a medical assistant should:

Accepted Answer

A)  erase the mistake and type in the correction 
B)  get written consent from the patient to correct the error 
C)  draw a line through the mistake, make and label it as a correction, initial and date it 
D)  draw a line through the error and enter the new information 
E)  destroy the entry and start over 
A)  erase the mistake and type in the correction 
B)  get written consent from the patient to correct the error 
C)  draw a line through the mistake, make and label it as a correction, initial and date it 
D)  draw a line through the error and enter the new information 
E)  destroy the entry and start over

Question 9

A nurse stops by the scene of an auto accident. She helps a conscious patient to remain calm and provides basic first aid to the patient. The patient later sues the nurse for malpractice. What state law will probably be used in the nurse's defense?

Accepted Answer

A)  informed consent rules 
B)  nursing practice act 
C)  emergency rules of the road 
D)  Good Samaritan Act 
E)  medical practice act 
A)  informed consent rules 
B)  nursing practice act 
C)  emergency rules of the road 
D)  Good Samaritan Act 
E)  medical practice act

Question 10

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?

Accepted Answer

A)  Release the entire record, not just the information requested. 
B)  Include the patient's name, address, and date of birth on the authorization. 
C)  Warn the patient that once authorization is given, it cannot be rescinded. 
D)  Receive a verbal authorization from the patient prior to release of the record. 
E)  Receive specific approval from the patient, even with a general authorization on file. 
A)  Release the entire record, not just the information requested. 
B)  Include the patient's name, address, and date of birth on the authorization. 
C)  Warn the patient that once authorization is given, it cannot be rescinded. 
D)  Receive a verbal authorization from the patient prior to release of the record. 
E)  Receive specific approval from the patient, even with a general authorization on file.

Question 11

Define health information technology.

Accepted Answer

The application of information processin

Question 12

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

Accepted Answer

A)  Jones v. Wade 
B)  Roe v. Wade 
C)  Wade v. Rose 
D)  Wade v. Davis 
E)  Roe v. Davis 
A)  Jones v. Wade 
B)  Roe v. Wade 
C)  Wade v. Rose 
D)  Wade v. Davis 
E)  Roe v. Davis

Question 13

Define fiduciary duty as it relates to a physician's role.

Accepted Answer

Fiduciary duty is a

Question 14

A physician is employed by a group practice. The physician decides to leave the practice and open his own private practice. May he have the records of the patients he is currently seeing? Why or why not?

Accepted Answer

The facility where the medical records w

Question 15

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

Accepted Answer

A)  notes regarding reaction to anesthesia 
B)  change of marital status 
C)  change in weight 
D)  notes regarding patient's participation in a rally 
E)  notes regarding patient's reaction to a new prescription 
A)  notes regarding reaction to anesthesia 
B)  change of marital status 
C)  change in weight 
D)  notes regarding patient's participation in a rally 
E)  notes regarding patient's reaction to a new prescription

Question 16

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

Accepted Answer

A)  patient care 
B)  patient education 
C)  patient compliance 
D)  patient maturity 
E)  patient's age 
A)  patient care 
B)  patient education 
C)  patient compliance 
D)  patient maturity 
E)  patient's age

Question 17

Describe the purpose of a Good Samaritan act.

Accepted Answer

A Good Samaritan act protects

Question 18

The five Cs are used to describe the attributes of entries into patients' medical records. Which of the following is not one of the five Cs?

Accepted Answer

A)  clean 
B)  complete 
C)  clear 
D)  correct 
E)  chronologically ordered 
A)  clean 
B)  complete 
C)  clear 
D)  correct 
E)  chronologically ordered

Question 19

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

Accepted Answer

A)  an emancipated minor 
B)  a married minor 
C)  a mature minor 
D)  an elderly patient 
E)  an adult who is mentally incompetent 
A)  an emancipated minor 
B)  a married minor 
C)  a mature minor 
D)  an elderly patient 
E)  an adult who is mentally incompetent

Question 20

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 Act?

Accepted Answer

A)  providing care in good faith 
B)  using due care under the circumstances 
C)  billing for services delivered at the site of the accident 
D)  acting within the scope of training 
E)  consulting with the EMTs on site 
A)  providing care in good faith 
B)  using due care under the circumstances 
C)  billing for services delivered at the site of the accident 
D)  acting within the scope of training 
E)  consulting with the EMTs on site

List the five C's that describe the attributes of a good entry into the medical record.

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

Medical records should be kept until the applicable statute of limitations period has elapsed. What is the usual timeframe for this period of time?

Which of the following is not a best practice guideline for maintaining confidentiality?

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

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

Medical records are:

To correct an error discovered after the patient's written copy of his or her medical records has been recorded, a medical assistant should:

A nurse stops by the scene of an auto accident. She helps a conscious patient to remain calm and provides basic first aid to the patient. The patient later sues the nurse for malpractice. What state law will probably be used in the nurse's defense?

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?

Define health information technology.

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

Define fiduciary duty as it relates to a physician's role.

A physician is employed by a group practice. The physician decides to leave the practice and open his own private practice. May he have the records of the patients he is currently seeing? Why or why not?

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

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

Describe the purpose of a Good Samaritan act.

The five Cs are used to describe the attributes of entries into patients' medical records. Which of the following is not one of the five Cs?

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

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 Act?

Introduction to Law and Ethics

Making Ethical Decisions

Working in Health Care

Law the Courts and Contracts

Professional Liability and Medical Malpractice

Defenses to Liability Suits

Privacy, Security, and Fraud

Physicians Public Duties and Responsibilities

Workplace Legalities

The Beginning of Life and Childhood

Death and Dying

Health Care Trends and Forecasts

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Exam 7: Medical Records and Informed Consent

List the five C's that describe the attributes of a good entry into the medical record.

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

Medical records should be kept until the applicable statute of limitations period has elapsed. What is the usual timeframe for this period of time?

Which of the following is not a best practice guideline for maintaining confidentiality?

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

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

Medical records are:

To correct an error discovered after the patient's written copy of his or her medical records has been recorded, a medical assistant should:

A nurse stops by the scene of an auto accident. She helps a conscious patient to remain calm and provides basic first aid to the patient. The patient later sues the nurse for malpractice. What state law will probably be used in the nurse's defense?

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?

Define health information technology.

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

Define fiduciary duty as it relates to a physician's role.

A physician is employed by a group practice. The physician decides to leave the practice and open his own private practice. May he have the records of the patients he is currently seeing? Why or why not?

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

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

Describe the purpose of a Good Samaritan act.

The five Cs are used to describe the attributes of entries into patients' medical records. Which of the following is not one of the five Cs?

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

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 Act?

Introduction to Law and Ethics

Making Ethical Decisions

Working in Health Care

Law the Courts and Contracts

Professional Liability and Medical Malpractice

Defenses to Liability Suits

Privacy, Security, and Fraud

Physicians Public Duties and Responsibilities

Workplace Legalities

The Beginning of Life and Childhood

Death and Dying

Health Care Trends and Forecasts

Filters