Protecting Patient Health Information
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What is the primary purpose of patient health information?
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a. Patient care
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Who is responsible for ensuring the qulity of health record documentation?
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c. provider
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Which of the following statements about the \"legal health record\" or the \"designated record set\" is incorrect?
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d. Designated record set is determined by the medical staff.
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Of the following, which is the most likely to happen to the health records of a physician's patient when a physician leaves an office practice?
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d. Retained by the practice
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The legal health record:
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b. will be disclosed upon request
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The legal health record must meet requirements as deinfed by the following:
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d. all of the above
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Verbal orders by telephone or in person are discouraged. IN cases where verbal orders are necessary, which of the following is the MOST effective method by which the risk of miscommunication can be lessened?
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a. Person receiving the order should red it back to insure that the order is correct.
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Which of the following exemplifies an acceptable patient record entry?
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c. Patient articulated pain level as a 6
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Staff disagreements within the heatlh record should be:
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a. Avoided
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Mrs. Bolton is an angry patient who resnets her physicians \"bossing her around,\" refuses to take a portion of the medications that the nurses bring to her pursuant to physician orders, and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient medical record is:
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b. Non-compliant and hostile toward staff
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LEGALLY, which of the following is the most important in determining the length of time that a hospital must retain medical records?
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c. statute of limitations
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Integrity refers to the
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b. accuracy and completness of information
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A goal of E-SIGN legislation was to:
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c. give electronic signatures increased legal standing
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Auto-authentication
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a. contradicts basic authentication standards
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Authentication methods include:
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d. all of the above
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Changes to health record entries:
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a. are acceptable in certain circumstances
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Printing paper documents from an EHR system:
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c. Creates legal challenges as to which document is the source of truth
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Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication?
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b. Nurse working on the unit where the patient is lcoated.
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A late entry into a heatlh record should:
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a. be identified as a late entry
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Abbreviations in the health record:
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b. should only have one meaning
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The integrity of EHR documentation is more susceptible than the paper healtgh record to which of the following functions?
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c. cut and paste
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Record maintenance and content requirements are established in part by;
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d. all of the above
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Dr. Harvey has changed a piece of data in a patient record. The information that tracks this change and enables a jury to see this change in a medical malpractice action is called:
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b. metadata
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Of the following, who has ultimate legal responsibility for the quality of care rendered in a healthcare organization?
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a. governing body
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What Act served to make electronic transactions as enforceable as paper transactions?
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b. Uniform Electronic Transactions Act
