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Under traditional rules of evidence, a medical/health record is considered ________ and is _________ into evidence. a. hearsay; admissibleb. hearsay; inadmissiblec. reliable; admissibled. reliable; inadmissible
Consent forms may be challenged on all the following grounds EXCEPT:a. wording was too technicalb. the treating physician obtained the patient's signaturec. it is written in a language that the patient could not understandd. the signature was not voluntary
The proper method for correcting a documentation error in a medical record is for the author to:a. draw an "X" through the incorrect documentationb. draw a single line through the incorrect information, date and initial the changec. white it out, date and initial the changed. remove the form from the chart and add a revised form
Which of the following health care systems have to comply with the requirements of the Freedom of Information Act?a. private hospitalsb. physicians' officesc. veterans' hospitalsd. single-day surgery clinics
When substituting a photocopy of the original record in response to legal process, which of the following can be helpful in convincing the court to accept the photocopy as a true and exact copy of the original?a. certificate of authenticationb. consent from the patientc. consent from the hospital administratord. correspondence from the attending physician
The minimum record retention period for patients who are minors is:a. age of majorityb. age of majority plus the statute of limitationsc. 5 years past treatmentd. 2 years past treatment
The hospital has a policy that states, "Original medical records may be removed from the Medical Record Department jurisdiction only by court order." Which situation would be a violation of the policy?a. A physician wishes to have the record sent to the physician lounge in the OR suite for final signaturesb. The Risk Manager requests the record for review by physicians at a quality assurance meeting c. A lawyer has subpoenaed the record for deposition d. The physician has been sued and wants to study the original record at home prior to his deposition
A health care organization's compliance plans should not only focus on regulatory compliance but also have a:a. strong personnel component that reduces the rapid turnover of nursing personnelb. coding compliance program that prevents fraudulent coding and billingc. component that increases the security of medical recordsd. substantial program that increase the availability of clinical data
what things do you need to look at when doing a performance appraisal:
It is common practice to forgo patient authorization for the release of information when the:a. patient is an employeeb. patient is a physicianc. patient has a direct transfer from the hospital to a long-term care facilityd. patient is incompetent
Who decides whether all or portions of the medical record will be received in evidence in a court of law?a. presiding judge/courtb. subpoenaing attorneyc. clerk of the courtd. defendant
Courts have released adoption records based on:a. the request of the adopteeb. the request of the biological parentsc. the Freedom of Information Actd. a court order for good cause
The written answers to questions (testimony) that you provide is a:a. interrogatoryb. depositionc. physical and mental examinationd. court order
Dr. Sam Vineyard improperly performed a knee replacement surgery, which caused the patient to develop an infection that lead to the amputation of the leg and thigh. The best term to describe the action performed is:a. misfeasanceb. malpracticec. nonfeasanced. malfeasance
Many states have recognized a minor's right to seek treatment without parental consent in all of the following situations EXCEPT a(n):a. minor seeking treatment for breast reductionb. minor seeking treatment for a sexually transmitted diseasec. minor seeking treatment for alcohol and substance abused. emancipated minor seeking treatment for breast enlargement
All of the following are areas in which electronically stored information, for example the electronic health record, differs from paper-based information EXCEPT:a. volumeb. metadatac. variety of sourcesd. confidentiality
In which of the following circumstances would release of information without the patient's authorization be permissible?a. release to an attorneyb. release to third-party payersc. release to state workers' compensation agenciesd. release to insurance companies
When a health care facility fails to investigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the health care facility can be held liable under:a. respondeat superiorb. corporate negligencec. contributory negligenced. general negligence
The Darling v. Charleston Community Memorial Hospital case established the following doctrine for hospitals to observe and changed the way hospitals dealt with liability.a. doctrine of respondeat superiorb. doctrine of continuing wrongc. doctrine of res ipsa loquiturd. doctrine of corporate negligence
All of the following need a proper authorization to access a patient's health information EXCEPT:a. local and state law enforcement officersb. IRS agentsc. medical examiners or coronersd. FBI agents

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