Deck 7: Medical Records and Informed Consent

Question 1

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

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

Answer 1

the patient

Question 2

A medical malpractice case has gone to trial. Which of the following types of testimony will prevail?

A) the written documentation in the medical record
B) a physician assistant's oral recollection of events
C) a physician's testimony
D) the patient's recollection of events
E) the patient's family members' recollection of events

Answer 2

the written documentation in the medical record

Question 3

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

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

Answer 3

when a subpoena duces tecum is issued

Question 4

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

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

Question 5

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) 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 6

A physician has a private practice employing a physician assistant, a nurse, and a medical assistant. The physician also has hospital privileges at a nearby facility. Who owns the medical records generated by both and him and the staff at the practice?

A) the public health department
B) the physician assistant if he or she treated the patient
C) the hospital
D) the insurance company paying the bills
E) the physician

Question 7

The law that mandated electronic health records and provides the rules for patient access to their records is:

A) OSHA
B) JCAHO
C) FDA
D) DOJ
E) HIPAA

Question 8

A subpoena duces tecum is issued for medical records of a patient who is suing the physician for malpractice. Which of the following is a guideline for sending this information?

A) Verify that the patient named was not a patient of the physician.
B) Notify the insurance company.
C) Review the record closely for any incriminating information and delete incriminating information.
D) Finish updating the record.
E) Offer sworn testimony regarding the record if instructed to do so by the court.

Question 9

Which of the following information is the federal statute known as the Confidentiality of Alcohol and Drug Abuse, Patient Records designed to protect?

A) victims of crimes committed by drug addicts
B) patient convictions
C) patient behavior
D) patient treatment
E) physician liability

Question 10

Allison is required to have a physical before starting her job as a nurse. Her employer pays for the physical. The employer should:

A) keep the physical exam records in Allison's personnel records
B) keep the physical exam records in a separate file from general personnel records
C) review the physical exam records and destroy them
D) review the physical exam records and return them to the provider
E) review the physical exam records and return them to Allison

Question 11

The doctrine of professional discretion pertains to medical record keeping. Which of the following describes this doctrine in more detail?

A) Patients should be able to obtain access to or copies of their medical records.
B) It is up to the discretion of the physician whether or not to allow all patients access to their medical records.
C) It is up to the discretion of the patient whether or not he or she may see the records.
D) It is up to the insurance company's discretion as to whether or not a patient may see his or her records.
E) It is up to the discretion of the facility whether or not to allow patients access to their medical records.

Question 12

Which of the following describes the proper protocol for the release of medical records?

A) Medical records may be released to third-party payers without patient consent.
B) When medical records are subpoenaed, the patient should be notified in writing.
C) Signed consent for medical records is not required for use in a lawsuit.
D) When medical records are released, the entire medical record should be released.
E) Only one year of a medical record should be released.

Question 13

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?

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

Question 14

Medical records are:

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 15

A plastic surgeon routinely photographs patients to document care. Which of the following accurately describes information that should be included on the consent form for this type of photography?

A) The patient understands that ownership rights to the photos belong to the patient.
B) The patient understands that the photos will be kept for an undetermined time period.
C) The patient understands that he or she cannot view the photographs.
D) The patient understands that authorization must be given to release photos outside the facility.
E) The patient understands that he or she will be paid for use of the photos in marketing for the practice.

Question 16

A physician has an obligation to his or her patient based on trust and confidence. What is the term for this obligation?

A) fiduciary duty
B) caring relationship
C) consent
D) doctrine of informed consent
E) Good Samaritan obligations

Question 17

A medical clinic does pre-employment physicals for a local employer. The employer pays for the physical exams. Who is the owner of the medical record in this case?

A) the employer
B) the patient
C) the medical clinic
D) the physician who did the physical
E) the government

Question 18

An addendum to an electronic health record (EHR) is a:

A) note made after the patient's which is entered into the EHR
B) surgical report added to the EHR
C) part of the financial information for payment of services
D) lab report added to the EHR
E) significant change or addition to the EHR

Question 19

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

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 20

A patient brings a medical malpractice suit against a hospital. The hospital claims that they have lost the records. What is the likely decision on the part of the court?

A) The case will be dismissed because there is no evidence.
B) It is up to the discretion of the physician whether or not to allow all patients access to their medical records.
C) A default judgment will be issued in favor of the plaintiff.
D) A default judgment will be issued in favor of the defendant.
E) The case will go to trial and testimony will be taken.

Question 21

For which of the following examples would implied consent not be legally appropriate?

A) a physician treating a patient for lung cancer
B) a patient providing a urine specimen to check for a UTI
C) a nurse taking a blood pressure in the exam room
D) a patient agrees to a test for HIV
E) a patient agrees to a chest x-ray

Question 22

What is an addendum to a medical record?

Question 23

Describe the process a provider should take to ensure confidentiality before photographing a patient.

Question 24

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

Question 25

Which of the following information is not usually included in the process of the doctrine of informed consent?

A) reputation of the physician performing the procedure
B) risks involved in the procedure
C) proposed modes of treatment
D) available alternative modes of treatment
E) why the treatment is necessary

Question 26

Which of the following is a result of the promotion of health information technology (HIT) in the medical industry?

A) decreased administrative efficiency
B) expanding access to affordable care
C) increased paperwork
D) increased medical errors
E) less improvement in health care quality

Question 27

Describe the process to correct an error in a written medical record.

Question 28

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

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

Question 29

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?

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 30

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

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

Question 31

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?

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

Question 32

Discuss the statute of limitations as it relates to the retention of medical records.

Question 33

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

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

Question 34

Jennifer's computer monitor is easily viewed by patients while they are sitting at her station. She notices that a patient is making an intent effort to read the information on the computer screen. The information concerns another patient that Jennifer had just talked with. What should Jennifer do?

A) Immediately shut down the computer.
B) Immediately speak to the patient.
C) Immediately switch to the current patient's screen.
D) Immediately distract the patient from viewing the monitor.
E) Put a piece of paper in front of the monitor.

Question 35

The doctrine of informed consent is the legal basis for advising patients regarding certain aspects of care. Under which of the following is this doctrine usually outlined?

A) local government regulations
B) hospital policy
C) state medical practice acts
D) federal medical practice acts
E) the American Medical Association

Question 36

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

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

Question 37

Identify five purposes for the medical record.

Question 38

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

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 39

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?

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

Question 40

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?

Question 41

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

Question 42

Define health information technology.

Question 43

Identify at least four guidelines that should be in place to ensure that confidentiality is not breached when employees use photocopiers and printers.

Question 44

Identify those individuals who may not give informed consent.

Question 45

What is the purpose of the federal statute entitled Confidentiality of Alcohol and Drug Abuse, Patient Records?

Question 46

Describe the doctrine of professional discretion as used by physicians and other health care providers.

Question 47

What are the elements of the doctrine of informed consent?

Question 48

Describe the circumstances where the Good Samaritan principles are used as a defense in a medical negligence lawsuit.

Question 49

Describe the purpose of a Good Samaritan act.

Question 50

Identify at least four areas where the federal government maintains that the broad use of information technology will improve patient care.