Deck 11: Specialized Patient Records

Question 1

Substance abuse health information is _____.

A) Included with any discovery request
B) Not released under any circumstances
C) Obtained with a court order only
D) Released via specific authorization

Answer 1

Released via specific authorization

Question 2

Which are subject to federal regulations regarding drug and alcohol treatment programs?

A) Facilities that provide general health care and substance abuse diagnosis/treatment.
B) General hospitals that operate a substance abuse unit that diagnoses and treats patients.
C) Mental health care organizations that provide long term care for psychiatric patients.
D) Physician offices that provide family medicine care, including treatment of anxiety.

Answer 2

General hospitals that operate a substance abuse unit that diagnoses and treats patients.

Question 3

Release of information may be made without patient consent in the event that _____.

A) An emergency situation exists, requiring patient records
B) Patients infected with HIV present a community health risk
C) Minor patients who undergo medical care sign a waiver
D) Treating facilities establish a policy prohibiting patient consent

Answer 3

An emergency situation exists, requiring patient records

Question 4

Which statement about the substance abuse treatment is true?

A) Depending on their age, minors are permitted to sign a consent to treatment.
B) In certain circumstances, parental consent is required to authorize treatment.
C) Minors are not permitted to authorize the release of substance abuse information.
D) Substance abuse facilities allow either the minor or parent to authorize treatment.

Question 5

Legal questions associated with _____ can be answered by referring to federal law.

A) communicable disease reporting
B) domestic violence
C) pregnancy termination
D) substance abuse

Question 6

The consent to release patient information is required when _____.

A) Audits are performed by a licensure agency
B) Information is used to screen for research
C) Litigators are seeking potential clients
D) The FDA recalls a medication or device

Question 7

A substance abuse treatment release of information is invalid if it fails to include the _____.

A) Automatic expiration date
B) Consent of legal counsel
C) Provider's signature
D) Purpose of disclosure

Question 8

Which statement is associated with federal regulations regarding the patient identification in a substance abuse program?

A) A substance abuse treatment facility has an unconditional obligation not to identify patients who have been treated.
B) Federal regulations prevent a substance abuse program from disclosing patients who were not treated in their program.
C) General hospitals are prohibited from revealing patient admission status, even when the diagnosis is not substance abuse related.
D) Providers are permitted to release patient identification information related to substance abuse treatment at their office.

Question 9

Federal regulations about the confidentiality of substance abuse records _____.

A) Differentiate between methadone programs and other substance abuse programs in that methadone programs are not impacted by federal regulations
B) Means that violations of confidentiality regarding substance abuse records are to be reported to the United States Federal Bureau of Investigations
C) Protect substance abuse patients from being more vulnerable for seeking treatment compared with substance abuse patient who do not seek treatment
D) Require a minimum fine of $10,000 for a first offense for breaching the confidentiality of patient substance abuse records plus one year of jail time

Question 10

A valid release of substance abuse treatment information includes a(n) _____.

A) General description about services provided to the patient
B) Overview about the program's goals and objectives
C) Provision that indemnifies the patient from any harm
D) Statement as to who is to receive the information

Question 11

A notice regarding redisclosure of information of substance abuse treatment records _____.

A) applies only to litigation
B) is needed for minor patients only
C) must accompany any disclosure
D) varies among states

Question 12

When a substance abuse treatment program is acquired by another program, the next course of action is that _____.

A) All of the patient records are transferred to the new program for maintenance and storage by the new substance abuse program
B) If any patients refuse consent to transfer, those records may be destroyed or retained in compliance with the statute of limitations
C) Records are destroyed by an appropriate method in order to prevent a breach of HIPAA privacy and security rules
D) The records are made available to the substance abuse patients so that they can maintain and store them for their own use

Question 13

Discovery requests for information from a patient records must be complied with when _____.

A) Court orders authorizing disclosure are based on a finding of good cause
B) Evidence of a patient's substance abuse is necessary for legal proceedings
C) Requested by a law enforcement agency and delivered by a court officer
D) Served without a subpoena duces tecum, and records are is part of a defense

Question 14

Specialized patient records are especially characterized as _____.

A) Being voluminous, creating storage issues
B) Containing entries from different specialties
C) Including medication administration records
D) Requiring specialized health information staff

Question 15

State laws regarding substance abuse records _____.

A) are unnecessary as federal law extends to state jurisdiction
B) may be equal to, less restrictive than, or more restrictive than federal law
C) prevent the patient's access to his own health records
D) take precedence over federal laws in the event of a conflict

Question 16

Which federal government official has the power to promulgate rules and regulations?

A) CDC Director
B) DHHS Secretary
C) FDA Chairperson
D) Surgeon General

Question 17

An invalid release of information contains _____.

A) Conditions of revocation
B) Dates of expiration
C) Information known to be false
D) Requests for minor patient records

Question 18

A specialized patient record contains diagnoses regarding _____,

A) autoimmune disease
B) cancer therapies
C) mental illness
D) physical medicine

Question 19

What are two main differences between mental health records and general health records?

A) Accurate provider documentation as well as timely entries are stricter for mental health records as compared with general health records
B) Additional requirements for patient record content and more stringent privacy requirements are associated with mental health records
C) Medical record retention regulations and policies as well as issues related to timely entries are more stringent for general health records
D) The accuracy of entries in both types of patient records as well as consents required for the release of information are subject to HIPAA regulations

Question 20

Federal confidentiality requirements are provided to a patient when _____.

A) Facilities receive a discovery request pursuant to a lawsuit
B) Patients are admitted to a substance abuse treatment program
C) They are discharged from a substance abuse treatment program
D) Payers request records to verify treatment prior to approving payment

Question 21

In addition to standard documentation requirements, the Joint Commission requires _____ to be documented in mental health records.

A) Benefits of treatment to be explained to third-party payers
B) Involvement of the family members in treatment programs
C) Legal status of family members and friends of the patient
D) Provision of educational benefits by the state programs

Question 22

Accrediting standards _____.

A) Are enforceable by law, regardless of whether federal or state in origin
B) Demonstrate that a facility needs to improve treatment provision and staff
C) Have no bearing on malpractice or negligence actions brought by patients
D) May be used in establishing a standard of care during a negligence action

Question 23

The Genetic Information Non-Discrimination Act (GINA) includes provisions for _____.

A) Individual states that enact less stringent laws regarding genetic testing so patients are exploited
B) Limiting the liability of employers and third-party payers when genetic testing results are used
C) Notifying family members of a research participant who carries particular genetic trait(s)
D) Providing protection that encourages individuals to participate in clinical research studies

Question 24

HIPAA addresses genetic testing by _____.

A) Allowing pre-employment screening of prospective employees prior to hiring them
B) Determining insurance premiums criteria (e.g., charging higher premiums)
C) Prohibiting it from being considered a preexisting condition for health insurance
D) Requiring it for government employees for the purpose of granting promotions

Question 25

The personal record relative to mental health care _____.

A) Always is substituted for documented progress notes
B) Can be maintained by patients or their family members
C) Is required, according to federal or state law
D) Might not be subject to discovery in a legal proceeding

Question 26

Which is required of psychiatric facilities that receive Medicare funds?

A) Adherence to conditions of participation for documentation.
B) Compliance with state mental health codes and regulations.
C) Provision for signed disclosure with each billing submission.
D) Requirement that patients are informed about record audits.

Question 27

The proper disclosure of home health care records is regulated by _____.

A) Family members of the patient
B) Health care facility policies
C) Medicare conditions of participation
D) Patient legal representatives

Question 28

The Genetic Information Non-Discrimination Act (GINA) _____.

A) Allows payers to collect genetic information as part of enrollment in a plan if it does not use the information to establish rates
B) Allows labor unions to exclude or expel a union member based on genetic testing, whether or not the member loses his job
C) Prohibits employers from requiring genetic testing prior to hiring employees, but may use previous genetic information as a consideration
D) Prohibits third-party payers from raising health insurance rates on a group or individual identified by genetic testing

Question 29

Standards that apply to facilities providing mental health, mental retardation, and developmental disability services are promulgated by the _____.

A) Americans with Disabilities Association
B) Department of Health and Human Services
C) Joint Commission
D) Office of the Surgeon General

Question 30

Patient notice is when a patient must be given notice of federal confidentiality requirements upon admission to the program or soon after.

Question 31

Disclosure without written patient authorization is fine in emergency situation.

Question 32

The release of mental health information is _____.

A) Not allowed to be revoked by the patient or any of her family members
B) Required when the facility's representative signs the release authorization
C) Strictly prohibited under any circumstance, regardless of court involvement
D) Subject to strict rules regarding confidentiality, pursuant to individual state laws

Question 33

The disclosure of mental health records to _____ may be made without express patient authorization.

A) Attorneys requesting information through discovery
B) Clergy and representatives of the patient's church
C) Family members of the mental healthcare patient
D) Treating healthcare personnel within the facility

Question 34

Medicare conditions of participation require that home health ____.

A) Patients be informed of rights prior to billing
B) Records be destroyed upon patient discharge
C) Staff maintain certain professional qualifications
D) Treatment be provided free of charge to patients

Question 35

If the patient does not sign an authorization to release information to the _____, the disclosure of mental health records is prohibited.

A) Agency that has custody of the patient
B) Facility's legal counsel
C) Physician providing healthcare
D) Patient's employer

Question 36

State laws may provide additional requirements regarding mental health care documentation in excess of federal regulations, such as _____.

A) Companies used to purchase physical restraints
B) Jury sequestering during trials involving patients
C) Staffing requirements for electroshock therapy
D) Written program plans with goals of treatment

Question 37

Genetic information _____.

A) Can be found in different forms and in different part of a health record
B) Is protected from discrimination by the Health and Human Services Dept.
C) Never impacts potential or current employers' actions against employees
D) Provides a look into past health information about a particular patient

Question 38

How does the law speak to mandatory testing?

A) It may be enforced through a court order.
B) Is not enforceable regarding HIV.
C) Statutory authority only applies to individuals.
D) It would violate the constitutional rights of a sexual offender if enforced.

Question 39

The official record regarding mental health care is _____.

A) Documented by providers and includes care and treatment
B) Maintained separately from the general patient record
C) Not required to be maintained by federal or state law
D) Stored by the clinicians, who have sole possession

Question 40

Pretest counseling provided to a patient for HIV testing includes _____.

A) Dispensing condoms, listing methods of transmitting disease, and explaining the types of tests
B) How to obtain clean needles, explaining test results, and reducing risk of transmission
C) Information about the types of tests, testing methodology employed, and the meaning of test results
D) Explaining Methods of transmitting disease, test methodology, and race most affected by HIV

Question 41

Mental health records can be released just like a general medical record.