question

Who has the legal right to refuse treatment?

answer

Juanita, who is 98 yrs old and of sound mind, Linda, who is 35 incompetent, and created a Living Will prior to becoming incompetent stating that she did not wish to be kept alive artificial mean.

question

Janice arrives at her physician's office for her 10:30 scheduled appointment and pays her office visit co-payment. Her physician examines her. Based on these facts, Janice's consent is

answer

implied

question

Mary is contemplating triple bypass surgery. Informed consent by her surgeon would typically contain which of the following

answer

Purpose of proposed procedure, risks assocated wth the procedure, non invasive treatment alternatives

question

Mary Little is 95 yrs old, While an inpatient at Gen. Hospital, she agrees that she doesnt want to be resuscitated if she would have a cardiopulmonary arrest. She sings a form and the physician documents it in the record. This best describes a

answer

DNR order

question

An advance directive is used to direct an individual's healthcare wishes in the event of

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Patient incapacitation

question

When a competent adult refuses treatment, a court may be required to balance the individual's privacy interests against

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The governments interest in protecting human life

question

carrying out the wishes stated in a living will applies to whch of the following patient's who is incompetent due to illness?

answer

a 40yr old man who was born with severe mental retardation

question

Emergences are an exception to the consent requirement for

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both adults and minors

question

The Uniform Health-Care Decisions Act ranks the next of Kin n the following order for medical decision making purposes

answer

spouse; adult child; parent ; adult sibling

question

Johnny is 12, his parents are divorced. In order for Johnny to receive medical treatment, generally

answer

one parent must consent

question

Mrs. Baker, who is a competent adult, has consulted her phys. For chronc URQ pain. Her phys. Recommends an elective cholestcystectomy. In this case, who must consent to the operative procedure?

answer

Mrs. Baker

question

the medical staff at Regency health is nationally revowned for its skill in performing cardac procedures. The nursing staff in the cardiac unit has noticed a signifcant lack of informed consents prior to performance procedures. Obtaining informed consent is the responsiblity of the

answer

Physician

question

Consent forms that allow for the performance of routine services by healthcare providers are

answer

general consents

question

in the Cruzan case, the court held that a person cannot assume end of life decisions on behalf of an incompetent person without _______ evidence that the person would refuse the continuation of life sustaining treatment.

answer

clear and convincing

question

What is the primary purpose of patient health information?

answer

patient care

question

Who is responsible for ensuring the quality of health record documentation?

answer

provider

question

Which of the following statements about the \"legal health record\" or the \"designated record set\" is incorrect?

answer

designated record set is determined by the medical staff

question

Of the following, which is the most likely to happen to the the health records of a phys. Patient when a phys. Leaves an office practice?

answer

retained by the practice

question

Once a paper health record has been converted onto microfilm, the info cannot be used as evidence. T/F

answer

False

question

The legal health record

answer

will be disclosed upon request

question

The legal health record must meet requirements as defined by the following

answer

federal regulations, state laws, accreditation body standards

question

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?

answer

person receiving the order should read iit back to insure that the order is correct

question

Which of the following exemplifes an acceptable patient record entry?

answer

patient articulated pain level as a 6

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Staff disagreements within the health record should be

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avoided

question

Mrs. Bolton is an angry patient who resents her phys. \"bossing her around\" refuese to take a portion of the medications that the nurses brng to her pursuant ot phys. Orders., and is verybally abusive to the patient care assistants. Of the following options, the most appropriate way ot document Mrs.Bolton;'s behavior in the medical record is

answer

non compliant and hostile toward staff

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legally, whch of the following is the most important in determining the length of time that a hospital must retain medical records?

answer

statute of limitations

question

Integrity refers to the

answer

accuracy and completeness of information

question

A goal of E_SIGN legislation was to

answer

give electronic signatures in all business meetings

question

Auto Authentication

answer

contradicts basic authentication standards

question

Authentication methods include

answer

handwritten signature, rubber signature stamp, electronic signature

question

Changes to health record entries

answer

are acceptable in certain circumstances

question

Printing paper Documents from an HER systems

answer

creates legal challenges as to which document is the source of truth

question

Which of the following personnel should be authorizes, per hospital policy, to take a physician's verbal order for the administration of medication?

answer

nurse working on the unit where the patient is located

question

A late entry into the health record should

answer

be identified as a late entry

question

Abbreviations in the health record

answer

should have only one meaning

question

The integrity of E H R documentation is more susceptible than the paper health record to which of the following functions?

answer

cut and paste

question

Record maintenance and contect requirements are established in part by

answer

dept of health and human services, joint commission, centers for medicare and medicaid services

question

Dr. Harvey has changed a piece of data in a patient record. The info that tracks this change and enables a jury to see this change in a medical malpractice action is called

answer

metadata

question

Of the following, who has ultimate legal responsibility for the quality of care rendered in a healthcare organization?

answer

governing body

HIM 115 Ch. 7&8 Review questions

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