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

answer

Patient incapacitation

question

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

answer

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

answer

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

question

Staff disagreements within the health record should be

answer

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

question

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

question

Discovery method that includes written questions that must be answered by potential witness

answer

interrogatories

question

state appellate court will hear a case dealing with an injury to a patient if the attorney appealing the case can prove

answer

an error of law occurred

question

when served with a court order directing the release of health records, an individual

answer

must comply with it

question

defendent fails to respond to a plaintiffs complaint, this may result in

answer

default judgment

question

following step should NOT be in health info dept procedure for preparing records in response to a subpoena

answer

remove pages containing detrimental info

question

from an evidentiary standpoint, incident reports

answer

should not be placed in the patients health record

question

medical record of kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wishes to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the

answer

business records exception

question

E-discovery rules are amendments to the _____ and were created in response to the tremendous volume of evidence, maintained in electronic format that is pertinent to lawsuits

answer

federal rules of civil procedure

question

Relevant eveidence

answer

tends to make the existance of a fact more or less probable

question

authentication of the record refers to

answer

establishment of its trustworthiness

question

environmental service employee of the hosp was called to the vascular surgery floor to clean the floor where a bag of potassium chloride spilled. after cleaning the floor, the employee failed to place a sign about a wet floor. mrs jones, a hosp visitor fell on the floor and got hurt. she incurred med expense of $560. and lost wages of $1000. she brought suit and the jury awarded her $1560, representing reimbursement of the med expenses and lost wages, plus $10k for jurors perceived recklessness on the part of the hosp. what is the $10k considered?

answer

punitive damages

question

HIM professional may attend leagal proceedings and testify as to

answer

authenticity of patients health record

question

hosp employee destroyed a health record so that its contents-which would be damaging to the employee- could not be used at trial. In legal terms the employees action constitutes

answer

spoliation

question

plaintiffs attorney has filed a state-law complaint in fed court. this is an error of what nature?

answer

procedural law

question

gloria kramer files a med malpractice lawsuit against dr johnson alleging that he committed negligence in the treatment of her diabetes. ms. kramers attorney insists that dr johnson can't speak about her med diagnosis becuase of physician-patient privilege. ms. kramers attorney

answer

is incorrect because she placed her med condition at issue

question

per the theory of physician/patient privilege, the right to waive the confidentiality of med info belongs to the

answer

patient

question

metadata is

answer

info about an electronic record

question

patient-privilege is defined by

answer

state law

question

subpoena duces tecum compels the recipient to

answer

bring records to a legal proceeding

question

defendant does not pay the damages awarded against her in a lawsuit. the court may order the seizure of a portion of her monthly wages to satisfy the judgment in an action called

answer

garnishment

question

if a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be followed in determining the case is

answer

stare decisis

question

collection of fed statutes is found in a

answer

code

question

concept of confidentiality applies to

answer

all data and info systems automated paper and verbal communications clinical, financial and business records

question

what is the intermediate court in the tiered structure of the state court system in nearly every state?

answer

appellate court

question

appellate courts are called ________ in federal court system

answer

circuit courts

question

regulations written by the state dept of health of US dept of health and human svcs are examples of

answer

administrative law

question

what law(s) involve govt as one of the parties?

answer

public law and criminal law

question

principle of law that serves as a guide in similar subsequent cases is called

answer

precedent

question

when a dispute is submitted to disinterested 3rd party and the 3rd party settles the case, this is

answer

arbitration

question

In the US, both the federal and state court systems us a _____ tier approach

answer

three

question

judicial decision may be based on the following types of actions

answer

disputes between individuals challenges to the constitutionality of a statute

question

legislative act passed by congress is an example of

answer

statutory law

question

what is the legal term used to define the protection of health info in the patient-provider relationship

answer

confidentiality

question

law based on judicial decision is called

answer

common law

question

mary has gone to her dr to discuss a med condition, what legal term best describes the type of communication that has occured between them

answer

priviledged communication

question

health info privacy has been established in all but one way

answer

constitutional right

question

custodian of health records refers to the individual within an organization is responsible for what action

answer

authorized to certify records supervise the inspection and copying of record testifies to the authenticity of records

question

term used to describe a patient has the right to maintain control over certain personal info is referred to as

answer

privacy

question

what is the term used to physical and electronic protection of health information

answer

security

question

what is also known as case law

answer

judicial law

question

party that presents evidence to disprove or disprove wrongdoing is the

answer

defendant

question

criminal law is a type of

answer

public law

question

US code is

answer

statutory law

question

under the concept of stare decisis

answer

lower courts look to higher courts

question

fed court has legal control over cases involving federal statutes. this legal contol is referred to as

answer

jurisdiction

question

this legal doctrine limits excessive litigation by prohibiting subsequent lawsuits about the same matter and involving the same parties once a decision has been made and all appeals have been exhausted

answer

res judicata

question

one restriction involving diversity jurisdiction is

answer

no plaintiff can be from the same state as any of the defendants

question

what court is the lowest court in the tiered structure of the state court system in nearly every state

answer

trial court

question

legislative act passed by congress is an example of

answer

statutory law

question

centers for disease control and prevention is located in the US

answer

dept of health & human services

question

federal court system, appellate courts are called

answer

circuit courts

question

legal matter was tried at the district court level and appealed to a fed appellate court. the case was appealed to the US supreme court, which declined to hear it. when the supreme court declined the case it

answer

denied cert

question

med malpractice appeal brought by carol agains mercy hosp has just concluded. the court reached a decision in favor of the hosp. the courts written determination that outlined the facts of the case and the legal theories followed to reach its outcome is an

answer

opinion

question

federal trial courts are called

answer

district courts

question

lawsuit is brought against a govt in

answer

court of claims

question

appellate courts hear appeals on final judgments of

answer

trial court decisions

question

US congress follows the model

answer

bicameral

question

agency that is heavily involved in combating medicare & medicaid fraud is

answer

inspector general for health & human services

question

in general, if virginia and texas laws conflict

answer

each state follows its own law

question

one or more advantages of mediation over utilizing the court system to resolve a dispute are

answer

time saving cost saving increase privacy

question

deeming authority has been granted by the US dept of HHS to the

answer

american osteopathic assoc

question

authority of TJC is mostequivalent to that of the

answer

commission of accreditation of rehab facilities

question

health information privacy protection has been established in court decisions, federal laws, state laws, but not

answer

constitutional rights

question

who owns the health record

answer

provider who generated the info

question

what is the term used most often to describe the indiv within an org who is responsible for protecting health info in conjuction with the court system

answer

custodian of record

question

many laws address patient privacy and confidentially. what other resourses address the providers resp for keeping health info private

answer

professional code of ethics

question

when someone is identified as an information steward, the indiv is resp for what activities

answer

integrity of electronic health record protecting loss or destruction of electroinic health record security of record

question

courts rules that guide a lawsuit from beginging to end is

answer

procedural law

question

class action lawsuits often involve

answer

groups of consumers against large entities

question

legal proceedings that accompany a lawsuit is

answer

litigation

question

dr huffman has been sued by a patient, he brings in the manufacturer as defendant. this process is

answer

joinder

question

service is

answer

notification of a lawsuit

question

process that allows evidence to be used in a court of law and considered by a jury is

answer

admissibility

question

mary has been deposed via a subpoena duces tecum. as the HIM director of hosp, she will bring the health record of a patient. her role is

answer

authenticate the records validity

question

court orders for the production of records

answer

do not require patient authorization

question

subpoena

answer

may be issued by a partys attorney

question

forma, written objections to subpeonas are often made in a

answer

motion to quash

question

when removing a health record in response to a subpoena duce tecum or a court order, what should be completed

answer

an index of contents

question

bench trial refers to a trial

answer

without a jury

question

excusal of a juror without a stated reason is

answer

peremptory challenge

question

the burdon of proof in which a plaintiff must prove that it was more likely than not that each element of a case was met is

answer

compensatory damages

question

actual damages, which compensate a plaintiff for losses incurred are

answer

compensatory

question

what type of damage is collected by implementing monetary caps to couteract lavish jury awards

answer

non-economic compensatory

question

party who appeals a trial court decision is

answer

appellant

question

if a plaintiff incurs $30k in damages realted to a medical expense and lost wages, what are these

answer

economic compensatory damages

question

mrs black sued mr brown for failing to return the clock. mr brown ignured mrs blacks lawsuit and she won a judgment of $1000. the court encumbered mr browns property so that when he tried to sell it 3 years later, he was unable to take any profit from the sale until mrs black was first pait this is

answer

judgment lien

question

when mr brown ignored mrs blacks lawsuit she won the case under what legal theory

answer

default judgment

question

dr howard is called to testify in a med malpractice case against dr hale. he testifies that base on his expertise of the subject matter. dr dale didnt commit med malpractice. dr howard is a/an

answer

expert witness

question

when an indiv represents herself as her own attorney she is

answer

acting pro se

question

when a patient discovers that a sponge has been left in his abdomen, the patient brings a lawsuit. to do this the patient must document and serve his allegations to the surgeon in a legal document called

answer

complaint

question

lawsuit has been filed against a hosp for bodily injuries allegedly suffered by a patient. legal counsel for the hosp believes the injuries are exaggerated. he used what discovery method to determine the true extent of the injuries

answer

physical exam

question

whether or not information may be introduced formally into evidence at trial is called

answer

admissibility

question

per the theory of physician/patient privilege, the right to waive the confidentiality of medical info belongs to the

answer

patient

question

metadata is

answer

info about electronic record

question

legal hold

answer

is issued by a court if there is concern about destruction of info during litigation

question

authenticiation of a record refers to

answer

establishment of its baseline trustworthiness

question

health record is representative of what type of evidence

answer

demonstrative evidence

question

best evidence rule

answer

permits copies to be substituted in certain cercumstances

question

from an evidentiary standpoint, incident reports

answer

should not be placed in a patients health record

question

during a trial to determiine wheither dr smith was liable for medical malpractice, dr smith testified in his own defense. legally, dr smiths testimony was

answer

direct evidence

question

relevant evidence

answer

tends to make theexistence of a fact more or less probable

question

patient-provider privelege is defined by

answer

state law

question

medical record is admitted into evidence as an exception to what rule

answer

hearsay

question

HIM professional may attend legal proceedings and testify to

answer

authenticate the health record

question

subpoena duces tecum compels the recipient to NOT do;

answer

serve on a jury answer a complaint produce documents

question

what is issued by the court if there is concern that info may be destroyed iin cases of current or potential litigation

answer

legal hold

question

statement made to an attorney, psychologist or clergy that is protected from being revealed even in court is what type of communication

answer

privileged

question

when determining whether or not evidence should be admissible in a court proceeding, the judge bases his discision on

answer

best evidence rule hearsay exception business records exception

question

when determining whether or not health records are privileged, the HIM professional should refer to

answer

state statutes

question

what is not a difference between electronic and paper records

answer

confidentiality

question

what employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed

answer

computer forensics

question

during hospitalization, mrs jones went into shock. hot water bags and other restoratives were ordered by attending physician. because the temp of water bags was too high, and not checked by the nurse, mrs jones suffered painful and permanent injuries. in this instance who may be sued under the doctrine of respondent superior

answer

hospital

question

what type of damages have been primary targets of tort reform legislation

answer

non-economic compensatory damages

question

what is the term to denote a cause of action when a physician fails to perform with reasonable skill and care

answer

negligence

question

if the court allows the plaintiff to only recover damgages to the extent (percentage) he was responsible for harm, what defense has the court applied to its final judgment

answer

comparative negligence

question

scalpal was left in a ptient during an exploratory aparotomy. additional surgery was required to remove the scalpel. based on the facts, what rule applies

answer

res ipse loquitur

question

unlawful intusion on an individual is considered

answer

invasion of privacy

question

burden of proof usually falls upon the plaintiff, except in case which apply the principle of

answer

res ipsa loquitur

question

what term denotes the suspension of the start of the statute of limitations clock

answer

tolling

question

the most likely cause of action from intentional touching by a healthcare provider, without patients consent is

answer

battery

question

conduct which places a person in reasonable apprehension of being touched in a manner that is insulting , provoking or physically injurious is

answer

assault

question

patient sued for negligent care. dr smith produced evidence showing that the patients poor medical outcome was due to the patients failure to follow his treatment plan and take the meds. if a court refuses to grant the patient any money damages because the patients actions contributed to the harm, what defense has the court applied to its final judgment

answer

contributory negligence

question

statute of limitations generally refers to

answer

period of time within which a lawsuit must be brought

question

patient is treated in er for laceration of the foot. the patient is given written instructions by the dr to have the sutures out in 3 days which the patient fails to do. an infection ensues resulting in permanent damage to the foot. the patient sues the surgeon for negligence and the surgeon uses the er record to prove what type of defense

answer

contibutory negiligence

question

what is a valid defense to a claim of defamation

answer

info was not published to a third party info was spoken only , it was not in writing communication was privileged because it was an issue of public safety

question

assault and battery fall under the category of

answer

intentional tort

question

what elements must be present in order for damages in a negligence action be awarded

answer

injury, duty to care, breach of duty, causation

question

proximate cause is based on whether or not it was ___ that the defendants breach of duty ould cause harm

answer

forseeable

question

johnny died as a result of an adverse reaction to meds given during surgery at mercy hosp, a joint commission accredited facility. the hosp had consistently failed to enforce TJC stancdards requiring the presence of a complete history and physical exam on the patients chart prior to surgery. because of the absence of a history and physical exam on the patients chart and the info it would have contained regarding drug allergies, the hosp may be found to have committed

answer

breach of duty

question

during a hearing to determint workers comp benefits for tom, his med records from dr loop revealed that tom is HIV+. this info had been entered into toms chart erroneously and was informormation about another patient. Tom is not HIV+. Tom filed a defamation lawsuit against dr loop and his physician practice. what will be the most likey outcome

answer

no defamatiion on liability because of the absolute privlege defense

question

most likely successful cause of action resulting from intentional touching by a healthcare provider w/o patients consent is

answer

batter

question

which elements must be present in order for damages in a negligence action to be awarded

answer

injury, duty of care, breach of duty, causation

question

assault and battery falls under the category of

answer

intentional tort

question

what type of damages have been primary targets of tort reform legislation

answer

noneconomic compensatory damages

question

what are the 2 types of causation necesary to meet the causation element of negligence

answer

actual and proximate

question

if a court allows the plaintiff to only recover damages to the extent he was not responsible for the harm, what defense has the court applied to its final judgement

answer

comparative negligence

question

intentional confinement of an individual against his wishes may be legally defensible if

answer

a mentally ill patient is a danger to self and others an indiv has a dangerous contagious disease

question

although a couse of action for false impreonment may result if a hosp retains a patient against their will, a hosp may be protected from liability if the patient

answer

is a danger to himself or others has a highly contagious disease

question

hosp is held liable in its own right for the harm that the physicians on its medical staff couase to a patient, the legal theory being applied is

answer

respondeat superior

question

what is an artificial being created per state statutory authority

answer

corporation

question

what characterizes a corporation

answer

it is separate from its owners or incorporators it can sue or be sued it can continue to exist despite an owners death

question

piercing the corporate veil refers to

answer

holding corporation owners liable for bad acts

question

not for profit corp may

answer

pay reasonable salaries to its employees

question

bylaws

answer

are the internal rules of an organization

question

not for profit corp that is formed for a charitable purpose

answer

must meet irs established criteria to be tax exempt

question

fiduciarty duty includes

answer

duty of loyalty duty of responsibility

question

ultra vires acts are those that

answer

exceed a corporations powers

question

general hosp is a 1000 bed facility. mercy hosp is a 100 bed facility. they join to form one corp, which is named general hosp. the restructuring that has most likely occured is a

answer

acquisition

question

contracts

answer

must contain an offer and acceptance

question

physician has been found to have breached his contract with a patient through abandonment. as a remedy, the court may order the following

answer

compensatory damages

question

term used to describe standard contract terms is

answer

boilerplate

question

learned intermediary defense used by HIT vendors, who is the learned intermediary

answer

physician

question

what is not a federal antitrust law

answer

HIPPA

question

What are federal antitrust laws

answer

sherman act clayton act federal trade commission act

question

when two or more entities at different levels in a distribution chain act together to restrain trade, this is

answer

vertical restraint of trade

question

what act offers both civil and criminal penalties

answer

sherman act

question

what actions related to the medical staff might raise antitrust issues

answer

excluding entire class of practitioners from medical staff membership

question

economic credentialing

answer

may be associated with physicians who have an ownership in competing hospitals may be based on a perceived loss of loyalty by a physician may be associated with a review of a physicans volume of cases

question

noncompete agreements

answer

might violate antitrust law

question

what is NOT a defense for nonperformance of a contract

answer

specific performance

question

what is a defense for nonperformance of a contract

answer

fraud mistake of fact duress

question

what characterizes a joint venture

answer

created for a specific purpose designed to have a limited lifespan

question

publicly held corp

answer

generally has thousands of shareholders

question

what describes a responsibility of corps governing board members

answer

appointing medical staff members

question

what is NOT a required element for piercing the corporate veil

answer

corp is a not for profit entity

question

what is a required element for pierceing the corporate veil

answer

complete domination of the corp by its owners control by owners was used to perpetrate a wrongful act corp control was the proximate cause of injury

question

challenges to tax exempt corps operating with a charitable purpose inclue

answer

aggressive billing practices insufficient charity care provided inflated billing practices toward the uninsured

question

legal health record must meet requirements as defined by

answer

federal regulations state laws accreditation body standards

question

once the paper has been converted to microfild or scanned into electronic record, the info cannot be used as evidence

answer

false

question

gold of E-sign legislation was to

answer

give electronic signatures increased legal standing

question

mary is 95, while an inpatient at general hosp she agrees she doesnt want to be resuscitated if she would have a cardiac arrest. she signs a form and the physician documents it in the record this is

answer

DNR order

question

janice arrives at her physicians office for her appt and pays her office visit co-pay. her dr examines her. based on these facts janices consent is

answer

implied

question

auto-authentication

answer

contradicts basic authentication standards

question

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 or most important use of patient health info

answer

patient care

question

dr harvey has changed a piece of datea in the patients record. the info that tracks this change and enables a jury to see this change in a med malpractice action is called

answer

metadata

question

printing paper documents for an EHR system

answer

creates legal challenges asto which document is the source of truth

question

advance directive is used to direct individuals health care wishes in the event of

answer

patient incapacitation

question

late entry into the health record should

answer

be identified as a late entry

question

record maintenance and content requiremenet are established in part by

answer

NY state doh TJC CMS

question

patient self determiniation act requires health care providers to

answer

inform patients of their right to creat advance directives document the presence or absence of advanced directives in the patient health record

question

abbreviations in the health record

answer

should have only one meaning

question

what is most likely to happen to the health records of a physicians patient when a physician leaves an office practice

answer

retained by the practice

question

mary is contemplating triple bypass surgery. informed consent by her surgeon would typically contain what elements

answer

purpose of the proposed procedure risks associated with the procedure non invasive treatment alternatives

question

staff disagreements within the health record should be

answer

avoided

question

mrs bolton is an angry patient who resents her dr \"bossing her around\". she refuses to take meds the nurse bring to her pursuant to drs orders and is verbally abusive to patient care assts. what is appropriate way to document her behavior in the record

answer

noncompliant and hostile toward staff

question

emergencies are a exception to the consent requrement for

answer

adults and minors

question

mrs davis is preparing to undergo hernia repair sugery . who should obtain the informed consent

answer

the surgeon doing the surgery

question

changes to health record entries

answer

are indicative of negligent care

question

legally, what is most important in determing the length of time that a hosp must retain records

answer

statute of limitations

question

uniform health care decision acts ranks next of kin for adults in what order for medical decision making

answer

spouse, adult child, parent, adult sibling

question

Johnny is 12 and his parents are divorced. in order for johnny to receive medical treatment, who can consent

answer

one parent must consent

question

physician who performs a surgical procedure on a patient without obtaing consent may be liable for

answer

battery

question

consent that is conveyed through spken or written words is

answer

express

question

consent that is conveyed through a persons conduct is

answer

implied

question

indiv is in an emergency condition and does not have capacity to communicate consent

answer

consent is implied by law

question

patient signs a consent form ,authorizing hsop staff to perform interventions necessary for overall medical care. this consent is

answer

general

question

informed consent requires informing the patient of

answer

nature and purpose of proposed treatment risks and benefits of proposed treatment alternatives to proposed treatment

question

proposed med intervention is related to a research study

answer

institutional review board approval is required

question

laws that require drivers to consent to blood alcohol tests, with penalties for refusal, probably exist to

answer

protect the public

question

under the common rule, informed consent for human subjects in research studies may be waived if

answer

the institutional review board approves a waiver

question

GINA applies to

answer

health insurers group health plans employers with 15 or more employees

question

GINA

answer

prohibits discrimination based on genetic info

question

under HIPAA, compound authorizations

answer

combine informed consent with authorization for use and disclosure of a research subjects health info

question

advance directives

answer

provide a way for physicians to ensure that life saving treatment is given, regardless of an indivuals wishes

question

if it is not durable, a POA is effective

answer

only when the principle has capacity

question

living will

answer

expresses an indiv healthcare wishes when specific health conditions exist

question

do not resuscitate order

answer

is a type of advance directive is used only in emergency situations may be revoked at any time

question

uniform anatomical gift act

answer

promotes consistency among state laws provides suggested standards for all aspects of organ donation includes an opt in system for organ donation

question

when a competent adult refuses to consent to lifesaving treatment , the two competing sets of interest that come into play are the indiv privacy interest and

answer

the governments interest in protecting and preserving human life

question

re quinlan the court held that

answer

an incompetent indiv has a right of privacy to terminate treatment

question

cruzan case, the missouri supreme court held that no one can make end of life choices on behalf of an incompetent person w/o

answer

clear and convincing evidence

question

end of life controversy in the terri schiavo case included

answer

a question about teh authority of legislative bodies to intervene in judicial matters

question

uniform health care decisions act

answer

provides an additional option to creating advance directives

question

emancipated minors are defined as those who have

answer

been afforded legal status as an adult

question

state laws most likely permit a monir to consent on their own behalf for

answer

alcohol addiction

question

frances has been experience abdominal pain. removal of her gallbladder has been recommended. who is resp to obtain her informed consent

answer

the physician who will perform the surger

question

uniform photographic copies of business and public records as evidence act does what

answer

allows record reproductions to be admited as evidence

question

legal health record or designated record set is

answer

designated record set is defined by HIPAA legislation legal health recores is defined by the facility legal health record my not include all of the info in the designated record set

question

destruciton of health records

answer

may be a prudent business practice

question

legal health record

answer

is the record that is disclosed upon request

question

verbal orders by phone or in person are discouraged. in cases where verbal orders are necessary, what is the most effective method by which the risk of miscommunication can be lessened

answer

person receiving order should read it back to insure the order is correct

question

integrity referes to

answer

accuracy and completeness of info

question

authentication methods include

answer

handwritten signature rubber stamp signature electronic signature

question

integrity of EHR documentation is more susceptible that paper health record to what function

answer

cut and paste

question

who has ultimate legal responsibility for the quality of care rendered in a healthcare org

answer

governing body

question

what act served to make electronic transactions as enforeable as paper

answer

uniform electronic transactions act

question

countersignature

answer

signifies review and evaluation of the first providers entry

question

error in a paper health record should be

answer

crossed out so that it can be seen but not relied on

question

personal health record

answer

may be housed in a system that a provider owns and controls

question

Discovery method that includes written questions that must be answered by potential witness

answer

interrogatories

question

a state appellate court will hear a case dealing with an injury to a patient if the attorney appealing the case can prove

answer

an error of law occurred

question

when served with a court order directing the release of health records, an individual

answer

must comply with it

question

a defendent fails to respond to a plaintiffs complaint, this may result in

answer

default judgment

question

the following step should NOT be in health info dept procedure for preparing records in response to a subpoena

answer

remove pages containing detrimental info

question

from an evidentiary standpoint, incident reports

answer

should not be placed in the patients health record

question

the medical record of kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wishes to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the

answer

business records exception

question

E-discovery rules are amendments to the _____ and were created in response to the tremendous volume of evidence, maintained in electronic format that is pertinent to lawsuits

answer

federal rules of civil procedure

question

Relevant eveidence

answer

tends to make the existance of a fact more or less probable

question

authentication of the record refers to

answer

establishment of its trustworthiness

question

an environmental service employee of the hosp was called to the vascular surgery floor to clean the floor where a bag of potassium chloride spilled. after cleaning the floor, the employee failed to place a sign about a wet floor. mrs jones, a hosp visitor fell on the floor and got hurt. she incurred med expense of $560. and lost wages of $1000. she brought suit and the jury awarded her $1560, representing reimbursement of the med expenses and lost wages, plus $10k for jurors perceived recklessness on the part of the hosp. what is the $10k considered?

answer

punitive damages

question

a HIM professional may attend leagal proceedings and testify as to

answer

authenticity of patients health record

question

a hosp employee destroyed a health record so that its contents-which would be damaging to the employee- could not be used at trial. In legal terms the employees action constitutes

answer

spoliation

question

a plaintiffs attorney has filed a state-law complaint in fed court. this is an error of what nature?

answer

procedural law

question

gloria kramer files a med malpractice lawsuit against dr johnson alleging that he committed negligence in the treatment of her diabetes. ms. kramers attorney insists that dr johnson can't speak about her med diagnosis becuase of physician-patient privilege. ms. kramers attorney

answer

is incorrect because she placed her med condition at issue

question

per the theory of physician/patient privilege, the right to waive the confidentiality of med info belongs to the

answer

patient

question

metadata is

answer

info about an electronic record

question

patient-privilege is defined by

answer

state law

question

a subpoena duces tecum compels the recipient to

answer

bring records to a legal proceeding

question

a defendant does not pay the damages awarded against her in a lawsuit. the court may order the seizure of a portion of her monthly wages to satisfy the judgment in an action called

answer

garnishment

question

if a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be followed in determining the case is

answer

stare decisis

question

the collection of fed statutes is found in a

answer

code

question

the concept of confidentiality applies to

answer

all data and info systems automated paper and verbal communications clinical, financial and business records

question

what is the intermediate court in the tiered structure of the state court system in nearly every state?

answer

appellate court

question

appellate courts are called ________ in federal court system

answer

circuit courts

question

regulations written by the state dept of health of US dept of health and human svcs are examples of

answer

administrative law

question

what law(s) involve govt as one of the parties?

answer

public law and criminal law

question

a principle of law that serves as a guide in similar subsequent cases is called

answer

precedent

question

when a dispute is submitted to disinterested 3rd party and the 3rd party settles the case, this is

answer

arbitration

question

In the US, both the federal and state court systems us a _____ tier approach

answer

three

question

judicial decision may be based on the following types of actions

answer

disputes between individuals challenges to the constitutionality of a statute

question

a legislative act passed by congress is an example of

answer

statutory law

question

what is the legal term used to define the protection of health info in the patient-provider relationship

answer

confidentiality

question

law based on judicial decision is called

answer

common law

question

mary has gone to her dr to discuss a med condition, what legal term best describes the type of communication that has occured between them

answer

priviledged communication

question

health info privacy has been established in all but one way

answer

constitutional right

question

the custodian of health records refers to the individual within an organization is responsible for what action

answer

authorized to certify records supervise the inspection and copying of record testifies to the authenticity of records

question

the term used to describe a patient has the right to maintain control over certain personal info is referred to as

answer

privacy

question

what is the term used to physical and electronic protection of health information

answer

security

question

what is also known as case law

answer

judicial law

question

the party that presents evidence to disprove or disprove wrongdoing is the

answer

defendant

question

criminal law is a type of

answer

public law

question

the US code is

answer

statutory law

question

under the concept of stare decisis

answer

lower courts look to higher courts

question

a fed court has legal control over cases involving federal statutes. this legal contol is referred to as

answer

jurisdiction

question

this legal doctrine limits excessive litigation by prohibiting subsequent lawsuits about the same matter and involving the same parties once a decision has been made and all appeals have been exhausted

answer

res judicata

question

one restriction involving diversity jurisdiction is

answer

no plaintiff can be from the same state as any of the defendants

question

what court is the lowest court in the tiered structure of the state court system in nearly every state

answer

trial court

question

a legislative act passed by congress is an example of

answer

statutory law

question

the centers for disease control and prevention is located in the US

answer

dept of health & human services

question

In the federal court system, appellate courts are called

answer

circuit courts

question

a legal matter was tried at the district court level and appealed to a fed appellate court. the case was appealed to the US supreme court, which declined to hear it. when the supreme court declined the case it

answer

denied cert

question

a med malpractice appeal brought by carol agains mercy hosp has just concluded. the court reached a decision in favor of the hosp. the courts written determination that outlined the facts of the case and the legal theories followed to reach its outcome is an

answer

opinion

question

federal trial courts are called

answer

district courts

question

a lawsuit is brought against a govt in

answer

court of claims

question

appellate courts hear appeals on final judgments of

answer

trial court decisions

question

the US congress follows the model

answer

bicameral

question

an agency that is heavily involved in combating medicare & medicaid fraud is

answer

inspector general for health & human services

question

in general, if virginia and texas laws conflict

answer

each state follows its own law

question

one or more advantages of mediation over utilizing the court system to resolve a dispute are

answer

time saving cost saving increase privacy

question

deeming authority has been granted by the US dept of HHS to the

answer

american osteopathic assoc

question

the authority of TJC is mostequivalent to that of the

answer

commission of accreditation of rehab facilities

question

health information privacy protection has been established in court decisions, federal laws, state laws, but not

answer

constitutional rights

question

who owns the health record

answer

provider who generated the info

question

what is the term used most often to describe the indiv within an org who is responsible for protecting health info in conjuction with the court system

answer

custodian of record

question

many laws address patient privacy and confidentially. what other resourses address the providers resp for keeping health info private

answer

professional code of ethics

question

when someone is identified as an information steward, the indiv is resp for what activities

answer

integrity of electronic health record protecting loss or destruction of electroinic health record security of record

question

a courts rules that guide a lawsuit from beginging to end is

answer

procedural law

question

class action lawsuits often involve

answer

groups of consumers against large entities

question

the legal proceedings that accompany a lawsuit is

answer

litigation

question

dr huffman has been sued by a patient, he brings in the manufacturer as defendant. this process is

answer

joinder

question

service is

answer

notification of a lawsuit

question

the process that allows evidence to be used in a court of law and considered by a jury is

answer

admissibility

question

mary has been deposed via a subpoena duces tecum. as the HIM director of hosp, she will bring the health record of a patient. her role is

answer

authenticate the records validity

question

court orders for the production of records

answer

do not require patient authorization

question

a subpoena

answer

may be issued by a partys attorney

question

forma, written objections to subpeonas are often made in a

answer

motion to quash

question

when removing a health record in response to a subpoena duce tecum or a court order, what should be completed

answer

an index of contents

question

a bench trial refers to a trial

answer

without a jury

question

excusal of a juror without a stated reason is

answer

peremptory challenge

question

the burdon of proof in which a plaintiff must prove that it was more likely than not that each element of a case was met is

answer

compensatory damages

question

actual damages, which compensate a plaintiff for losses incurred are

answer

compensatory

question

what type of damage is collected by implementing monetary caps to couteract lavish jury awards

answer

non-economic compensatory

question

the party who appeals a trial court decision is

answer

appellant

question

if a intiff incurs $30k in damages realted to a medical expense and lost wages, what are these

answer

economic compensatory damages

question

mrs black sued mr brown for failing to return the clock. mr brown ignured mrs blacks lawsuit and she won a judgment of $1000. the court encumbered mr browns property so that when he tried to sell it 3 years later, he was unable to take any profit from the sale until mrs black was first pait this is

answer

judgment lien

question

when mr brown ignored mrs blacks lawsuit she won the case under what legal theory

answer

default judgment

question

dr howard is called to testify in a med malpractice case against dr hale. he testifies that base on his expertise of the subject matter. dr dale didnt commit med malpractice. dr howard is a/an

answer

expert witness

question

when an indiv represents herself as her own attorney she is

answer

acting pro se

question

when a patient discovers that a sponge has been left in his abdomen, the patient brings a lawsuit. to do this the patient must document and serve his allegations to the surgeon in a legal document called

answer

complaint

question

a lawsuite has been filed against a hosp for bodily injuries allegedly suffered by a patient. legal counsel for the hosp believes the injuries are exaggerated. he used what discovery method to determine the true extent of the injuries

answer

physical exam

question

whether or not information may be introduced formally into evidence at trial is called

answer

admissibility

question

per the theory of physician/patient privilege, the right to waive the confidentiality of medical info belongs to the

answer

patient

question

metadata is

answer

info about electronic record

question

a legal hold

answer

is issued by a court if there is concern about destruction of info during litigation

question

authenticiation of a record refers to

answer

establishment of its baseline trustworthiness

question

a health record is representative of what type of evidence

answer

demonstrative evidence

question

the best evidence rule

answer

permits copies to be substituted in certain cercumstances

question

from an evidentiary standpoint, incident reports

answer

should not be placed in a patients health record

question

during a trial to determiine wheither dr smith was liable for medical malpractice, dr smith testified in his own defense. legally, dr smiths testimony was

answer

direct evidence

question

relevant evidence

answer

tends to make theexistence of a fact more or less probable

question

patient-provider privelege is defined by

answer

state law

question

the medical record is admitted into evidence as an exception to what rule

answer

hearsay

question

the HIM professional may attend legal proceedings and testify to

answer

authenticate the health record

question

a subpoena duces tecum compels the recipient to NOT do;

answer

serve on a jury answer a complaint produce documents

question

what is issued by the court if there is concern that info may be destroyed iin cases of current or potential litigation

answer

legal hold

question

a statement made to an attorney, psychologist or clergy that is protected from being revealed even in court is what type of communication

answer

privileged

question

when determining whether or not evidence should be admissible in a court proceeding, the judge bases his discision on

answer

best evidence rule hearsay exception business records exception

question

when determining whether or not health records are privileged, the HIM professional should refer to

answer

state statutes

question

what is not a difference between electronic and paper records

answer

confidentiality

question

what employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed

answer

computer forensics

question

during hospitalization, mrs jones went into shock. hot water bags and other restoratives were ordered by attending physician. because the temp of water bags was too high, and not checked by the nurse, mrs jones suffered painful and permanent injuries. in this instance who may be sued under the doctrine of respondent superior

answer

hospital

question

what type of damages have been primary targets of tort reform legislation

answer

non-economic compensatory damages

question

what is the term to denote a cause of action when a physician fails to perform with reasonable skill and care

answer

negligence

question

if the court allows the plaintiff to only recover damgages to the extent (percentage) he was responsible for harm, what defense has the court applied to its final judgment

answer

comparative negligence

question

a scalpal was left in a ptient during an exploratory aparotomy. additional surgery was required to remove the scalpel. based on the facts, what rule applies

answer

res ipse loquitur

question

unlawful intusion on an individual is considered

answer

invasion of privacy

question

the burden of proof usually falls upon the plaintiff, except in case which apply the principle of

answer

res ipsa loquitur

question

what term denotes the suspension of the start of the statute of limitations clock

answer

tolling

question

the most likely cause of action from intentional touching by a healthcare provider, without patients consent is

answer

battery

question

conduct which places a person in reasonable apprehension of being touched in a manner that is insulting , provoking or physically injurious is

answer

assault

question

a patient sued for negligent care. dr smith produced evidence showing that the patients poor medical outcome was due to the patients failure to follow his treatment plan and take the meds. if a court refuses to grant the patient any money damages because the patients actions contributed to the harm, what defense has the court applied to its final judgment

answer

contributory negligence

question

the statute of limitations generally refers to

answer

period of time within which a lawsuit must be brought

question

a patient is treated in er for laceration of the foot. the patient is given written instructions by the dr to have the sutures out in 3 days which the patient fails to do. an infection ensues resulting in permanent damage to the foot. the patient sues the surgeon for negligence and the surgeon uses the er record to prove what type of defense

answer

contibutory negiligence

question

what is a valid defense to a claim of defamation

answer

info was not published to a third party info was spoken only , it was not in writing communication was privileged because it was an issue of public safety

question

assault and battery fall under the category of

answer

intentional tort

question

what elements must be present in order for damages in a negligence action be awarded

answer

injury, duty to care, breach of duty, causation

question

proximate cause is based on whether or not it was ___ that the defendants breach of duty ould cause harm

answer

forseeable

question

johnny died as a result of an adverse reaction to meds given during surgery at mercy hosp, a joint commission accredited facility. the hosp had consistently failed to enforce TJC stancdards requiring the presence of a complete history and physical exam on the patients chart prior to surgery. because of the absence of a history and physical exam on the patients chart and the info it would have contained regarding drug allergies, the hosp may be found to have committed

answer

breach of duty

question

during a hearing to determint workers comp benefits for tom, his med records from dr loop revealed that tom is HIV+. this info had been entered into toms chart erroneously and was informormation about another patient. Tom is not HIV+. Tom filed a defamation lawsuit against dr loop and his physician practice. what will be the most likey outcome

answer

no defamatiion on liability because of the absolute privlege defense

question

the most likely successful cause of action resulting from intentional touching by a healthcare provider w/o patients consent is

answer

batter

question

which elements must be present in order for damages in a negligence action to be awarded

answer

injury, duty of care, breach of duty, causation

question

assault and battery falls under the category of

answer

intentional tort

question

what type of damages have been primary targets of tort reform legislation

answer

noneconomic compensatory damages

question

what are the 2 types of causation necesary to meet the causation element of negligence

answer

actual and proximate

question

if a court allows the plaintiff to only recover damages to the extent he was not responsible for the harm, what defense has the court applied to its final judgement

answer

comparative negligence

question

intentional confinement of an individual against his wishes may be legally defensible if

answer

a mentally ill patient is a danger to self and others an indiv has a dangerous contagious disease

question

although a couse of action for false impreonment may result if a hosp retains a patient against their will, a hosp may be protected from liability if the patient

answer

is a danger to himself or others has a highly contagious disease

question

if a hosp is held liable in its own right for the harm that the physicians on its medical staff couase to a patient, the legal theory being applied is

answer

respondeat superior

question

what is an artificial being created per state statutory authority

answer

corporation

question

what characterizes a corporation

answer

it is separate from its owners or incorporators it can sue or be sued it can continue to exist despite an owners death

question

piercing the corporate veil refers to

answer

holding corporation owners liable for bad acts

question

a not for profit corp may

answer

pay reasonable salaries to its employees

question

bylaws

answer

are the internal rules of an organization

question

a not for profit corp that is formed for a charitable purpose

answer

must meet irs established criteria to be tax exempt

question

fiduciarty duty includes

answer

duty of loyalty duty of responsibility

question

ultra vires acts are those that

answer

exceed a corporations powers

question

general hosp is a 1000 bed facility. mercy hosp is a 100 bed facility. they join to form one corp, which is named general hosp. the restructuring that has most likely occured is a

answer

acquisition

question

contracts

answer

must contain an offer and acceptance

question

a physician has been found to have breached his contract with a patient through abandonment. as a remedy, the court may order the following

answer

compensatory damages

question

a term used to describe standard contract terms is

answer

boilerplate

question

in the learned intermediary defense used by HIT vendors, who is the learned intermediary

answer

physician

question

what is not a federal antitrust law

answer

HIPPA

question

What are federal antitrust laws

answer

sherman act clayton act federal trade commission act

question

when two or more entities at different levels in a distribution chain act together to restrain trade, this is

answer

vertical restraint of trade

question

what act offers both civil and criminal penalties

answer

sherman act

question

what actions related to the medical staff might raise antitrust issues

answer

excluding entire class of practitioners from medical staff membership

question

economic credentialing

answer

may be associated with physicians who have an ownership in competing hospitals may be based on a perceived loss of loyalty by a physician may be associated with a review of a physicans volume of cases

question

noncompete agreements

answer

might violate antitrust law

question

what is NOT a defense for nonperformance of a contract

answer

specific performance

question

what is a defense for nonperformance of a contract

answer

fraud mistake of fact duress

question

what characterizes a joint venture

answer

created for a specific purpose designed to have a limited lifespan

question

a publicly held corp

answer

generally has thousands of shareholders

question

what describes a responsibility of corps governing board members

answer

appointing medical staff members

question

what is NOT a required element for piercing the corporate veil

answer

corp is a not for profit entity

question

what is a required element for pierceing the corporate veil

answer

complete domination of the corp by its owners control by owners was used to perpetrate a wrongful act corp control was the proximate cause of injury

question

challenges to tax exempt corps operating with a charitable purpose inclue

answer

aggressive billing practices insufficient charity care provided inflated billing practices toward the uninsured

question

the legal health record must meet requirements as defined by

answer

federal regulations state laws accreditation body standards

question

once the paper has been converted to microfild or scanned into electronic record, the info cannot be used as evidence

answer

false

question

a gold of E-sign legislation was to

answer

give electronic signatures increased legal standing

question

mary is 95, while an inpatient at general hosp she agrees she doesnt want to be resuscitated if she would have a cardiac arrest. she signs a form and the physician documents it in the record this is

answer

DNR order

question

janice arrives at her physicians office for her appt and pays her office visit co-pay. her dr examines her. based on these facts janices consent is

answer

implied

question

auto-authentication

answer

contradicts basic authentication standards

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 or most important use of patient health info

answer

patient care

question

dr harvey has changed a piece of datea in the patients record. the info that tracks this change and enables a jury to see this change in a med malpractice action is called

answer

metadata

question

printing paper documents for an EHR system

answer

creates legal challenges asto which document is the source of truth

question

and advance directive is used to direct individuals health care wishes in the event of

answer

patient incapacitation

question

a late entry into the health record should

answer

be identified as a late entry

question

record maintenance and content requiremenet are established in part by

answer

NY state doh TJC CMS

question

the patient self determiniation act requires health care providers to

answer

inform patients of their right to creat advance directives document the presence or absence of advanced directives in the patient health record

question

abbreviations in the health record

answer

should have only one meaning

question

what is most likely to happen to the health records of a physicians patient when a physician leaves an office practice

answer

retained by the practice

question

mary is contemplating triple bypass surgery. informed consent by her surgeon would typically contain what elements

answer

purpose of the proposed procedure risks associated with the procedure non invasive treatment alternatives

question

staff disagreements within the health record should be

answer

avoided

question

mrs bolton is an angry patient who resents her dr \"bossing her around\". she refuses to take meds the nurse bring to her pursuant to drs orders and is verbally abusive to patient care assts. what is appropriate way to document her behavior in the record

answer

noncompliant and hostile toward staff

question

emergencies are a exception to the consent requrement for

answer

adults and minors

question

mrs davis is preparing to undergo hernia repair sugery . who should obtain the informed consent

answer

the surgeon doing the surgery

question

changes to health record entries

answer

are indicative of negligent care

question

legally, what is most important in determing the length of time that a hosp must retain records

answer

statute of limitations

question

the uniform health care decision acts ranks next of kin for adults in what order for medical decision making

answer

spouse, adult child, parent, adult sibling

question

johnyy is 12 and his parents are divorced. in order for johnny to receive medical treatment, who can consent

answer

one parent must consent

question

a physician who performs a surgical procedure on a patient without obtaing consent may be liable for

answer

battery

question

consent that is conveyed through spken or written words is

answer

express

question

consent that is conveyed through a persons conduct is

answer

implied

question

if an indiv is in an emergency condition and does not have capacity to communicate consent

answer

consent is implied by law

question

a patient signs a consent form ,authorizing hsop staff to perform interventions necessary for overall medical care. this consent is

answer

general

question

informed consent requires informing the patient of

answer

nature and purpose of proposed treatment risks and benefits of proposed treatment alternatives to proposed treatment

question

if proposed med intervention is related to a research study

answer

institutional review board approval is required

question

laws that require drivers to consent to blood alcohol tests, with penalties for refusal, probably exist to

answer

protect the public

question

under the common rule, informed consent for human subjects in research studies may be waived if

answer

the institutional review board approves a waiver

question

GINA applies to

answer

health insurers group health plans employers with 15 or more employees

question

GINA

answer

prohibits discrimination based on genetic info

question

under HIPAA, compound authorizations

answer

combine informed consent with authorization for use and disclosure of a research subjects health info

question

advance directives

answer

provide a way for physicians to ensure that life saving treatment is given, regardless of an indivuals wishes

question

if it is not durable, a POA is effective

answer

only when the principle has capacity

question

a living will

answer

expresses an indiv healthcare wishes when specific health conditions exist

question

a do not resuscitate order

answer

is a type of advance directive is used only in emergency situations may be revoked at any time

question

the uniform anatomical gift act

answer

promotes consistency among state laws provides suggested standards for all aspects of organ donation includes an opt in system for organ donation

question

when a competent adult refuses to consent to lifesaving treatment , the two competing sets of interest that come into play are the indiv privacy interest and

answer

the governments interest in protecting and preserving human life

question

in re quinlan the court held that

answer

an incompetent indiv has a right of privacy to terminate treatment

question

In the cruzan case, the missouri supreme court held that no one can make end of life choices on behalf of an incompetent person w/o

answer

clear and convincing evidence

question

the endof life controversy in the terri schiavo case included

answer

a question about teh authority of legislative bodies to intervene in judicial matters

question

the uniform health care decisions act

answer

provides an additional option to creating advance directives

question

emancipated minors are defined as those who have

answer

been afforded legal status as an adult

question

state laws most likely permit a monir to consent on their own behalf for

answer

alcohol addiction

question

frances has been experience abdominal pain. removal of her gallbladder has been recommended. who is resp to obtain her informed consent

answer

the physician who will perform the surger

question

the uniform photographic copies of business and public records as evidence act does what

answer

allows record reproductions to be admited as evidence

question

the legal health record or designated record set is

answer

designated record set is defined by HIPAA legislation legal health recores is defined by the facility legal health record my not include all of the info in the designated record set

question

destruciton of health records

answer

may be a prudent business practice

question

the legal health record

answer

is the record that is disclosed upon request

question

verbal orders by phone or in person are discouraged. in cases where verbal orders are necessary, what is the most effective method by which the risk of miscommunication can be lessened

answer

person receiving order should read it back to insure the order is correct

question

integrity referes to

answer

accuracy and completeness of info

question

authentication methods include

answer

handwritten signature rubber stamp signature electronic signature

question

the integrity of EHR documentation is more susceptible that paper health record to what function

answer

cut and paste

question

who has ultimate legal responsibility for the quality of care rendered in a healthcare org

answer

governing body

question

what act served to make electronic transactions as enforeable as paper

answer

uniform electronic transactions act

question

a countersignature

answer

signifies review and evaluation of the first providers entry

question

an error in a paper health record should be

answer

crossed out so that it can be seen but not relied on

question

a personal health record

answer

may be housed in a system that a provider owns and controls

question

Law based upon judicial decision is called:

answer

Common law

question

The collection of federal statutes is found in a:

answer

Code

question

Which type of law involves the government as one of its parties?

answer

Public Law and criminal law

question

A legislative act passed by Congress is an example of:

answer

Statutory law

question

In general, if a South Carolina law and a North Carolina law conflict, whose law is follwed?

answer

Each state follows its own law

question

Judicial decisions may be based on what type of actions? a) disputes between individuals b) challenges to the constitutionality of a statute c) neither a nor b d) both a & b

answer

d) both a & b

question

If a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be follwed in determining this case is:

answer

Stare decisis

question

What is the name of the intermediate court in the tiered structure of the state court system in nearly every state?

answer

Appellate court

question

Appellate courts draft:

answer

Opinions

question

In the United States, both the Federal and the State court systems use the _______-tier approach.

answer

three

question

Statutory law derives from which branch of government?

answer

Legislative

question

Regulations written by a state department of health or the U.S. Department of Health and Human Services are examples of:

answer

Administrative law

question

\"Which of the following occupies the highest hierarchal position? a) Centers for Medicare and Medicaid Services b) National Institutes of Health c) Indian Health Service d) United States Department of Health and Human Services\"

answer

d) United States Department of Health and Human Services\"

question

The collection of federal statutory law is:

answer

United States Code

question

Diversity jurisdiction refers to the ability to bring legal action in a:

answer

Federal district court

question

Appellate courts are called _____ in the federal court system.

answer

Circuit courts

question

\"The standards of accrediting bodies such as The Joint Commission have the same legal authority as: a) regulations issued by an administrative agency b) s decision rendered by an appellate court c) a statute enacted by a legislature d) none of the above

answer

d) none of the above

question

When a dispute is submitted to a disinterested third party and the third party settles the case, this is called:

answer

Arbitration

question

A lawsuit has been filed by John Collins, a resident of VA, against a hospital in PA alleging the wrongful disclosure of a patients confidential information. This lawsuit could be filed in what type of court?

answer

Federal district court

question

A legal matter was tried at the district court level and appealed to a federal appellate court. The case is now being appealed to the United States Supreme Court. Which statement is most correct

answer

The U. S. Supreme Court will likely deny writ and decline this case for oral argument.

question

One or more advantages of arbitration over utilizing the court system to resolve a dispute is/are:

answer

Time saving, cost saving, and increased privacy

question

Which laws are synonymous terms for court decisions?

answer

Case law, common law, and judicial law

question

This type of law consists of rules and regulations issued by agencies that implement statutory law.

answer

Administrative law

question

A principle of law that serves as a guide in similar subsequent cases is called:

answer

Precedent

question

Alternate dispute resolution is an acceptable option to resolving cases via the court system for what type cases?

answer

Civil and criminal cases

question

A jury does not

answer

make determination of the law

question

An environmental service employee of the hospital is called to the vascular surgeon floor to clean the floor where a bag of Potassium chloride was spilled. After cleaning the floor, the employee failed to place any signs advising others of a wet floor. Mrs. Jones, a hospital employee fell on the floor and injured her back. She incurred medical expenses of $560.00 and loss wages in the amt of $1000.00. She brought suit and the jury awarded her $1560.00, representing reimbursement of the medical expenses and lost wages, plus $10k for the jurors; perceived recklessness on the part of the hospital. What is the $10k amt considered?

answer

punitive damages

question

a defendant does not pay the damages awarded against her in a lawsuit. The court may order the seizure of a portion of her monthly wages to satisfy the judment in an action called

answer

garnishment

question

a state appellete court will hear a case dealing with an injury to a patient if the atty appealing the case can prove

answer

an error of law occurred

question

the following type of damages has been the primary target of the tort reform legislation

answer

non economic compensatory damages

question

Mr. Green won a $500K lawsuit against Dr. Blue. Dr. Blue has appealed. Upon appeal, Mr. Green is referred to as

answer

respondent

question

Dr. Robert is being sued for negligence by one of his patients. Dr. roberts decides to represent himself as his own atty. Dr Roberts is

answer

acting pro se

question

When a patient discovers that a hemostat has been left in his abdomen by a surgeon, the patient must document and serve his allegations to the surgeon. The surgeon must respond via a legal document called:

answer

question

A plaintiff's attorney has filed a stat-law complaint in federal court. This is an error of what nature?

answer

procedural law

question

Service of summons and complaint: a) requires adequate notice to the defendent b) may occur in person or via mail c) both a and b d) none of the above

answer

c) both a and b

question

The Federal Rules of Civil Procedure apply to:

answer

federal district courts

question

A health information management professional may attend legal proceedings and testify as to:

answer

the authenticity of the patient's health record

question

Which of the following discovery methods is directed only towards parties involved in the litigation?

answer

interrogatories

question

A deposition:

answer

can be used to impeach a witness at trial

question

\"The Federal Rules of Civil Procedure address: a) trials b) federal district court procedures c) filing a lawsuit d) all of the above

answer

d) all of the above

question

When serves with a court order directing the release of health records, an individusl:

answer

must comply with it

question

A subpoena duces tecum compels the recipient to:

answer

bring records to a legal proceeding

question

A valid subpoena duces tecum seeking health records does NOT have to:

answer

be signed by the plaintiff and defendant

question

Rule 23 of the Federal Rules of Civil Procedure specifically provides for what type of legal action?

answer

class action

question

Information contained in a health record that is discoverable:

answer

may or may not be admissable

question

A lawsuit has been filed against Lewisville Hospital for bodily injuries allegedly suffered by a patient during his inpatient hospital stay. Legal counsel for Lewisville Hospital believes the injuries reported in the plaintiff's complaint are exaggerated and the following discovery method is employed to determine the true extent of the injuries:

answer

physical examination

question

The following step should NOT be included in a health information department's procedure for preparing health records in response to a subpoena:

answer

remove pages containing detrimental information

question

Whether or not information may be introduced formally into evidence at trial is called:

answer

admissibility

question

The medical record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wishes to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the:

answer

business records exception

question

E-Discovery rules are amendments to the _________ and were created in response to the tremendous volume of evidence, maintained in electronic format, that is pertinent to lawsuits.

answer

Federal rules of civil procedure

question

Per the theory of physician/patient privilege, the right to waive the confidentiality of medical information belongs to the

answer

patient

question

Meta data is

answer

information about an electronic record

question

A legal hold

answer

is issued by a court if there is concern about destruction of information during litigation

question

Authentication of a record refers to

answer

establishment of its baseline trustworthiness

question

A health record is representative of what type of evidence?

answer

demonstrative evidence

question

The best evidence rule:

answer

permits copies to be substituted in certain circumstances

question

Gloria Kramer files a medical malpractice lawsuit against Dr. Johnson, alleging that he committed negligence in the treatment of her diabetes. Ms. Kramer's attorney insists that Dr. Johnson cannot speak about of her medical diagnoses because of physician-patient privilege. Ms. Kramer's attorney:

answer

is incorrect because she placed her medical condition at issue

question

From an evidentiary standpoint, incident reports

answer

should not be placed in a patient's health record

question

During a trial to determine whether Dr. Smith was liable for medical malpractice, Dr. Smith testified in his own defense. Legally, Dr. Smith's testimony was:

answer

direct evidence

question

Relevant evidence

answer

tends to make the existence of a fact more or less probable

question

A hospital employee destroyed a health record so that its contents - which would be damaging to the employee - could not be used at trial. In legal terms, the employee's action constitutes:

answer

spoilation

question

A health information management professional may attend legal proceedings and testify as to:

answer

the authenticity of the patient's health record

question

Patient-provider privilege is defined by

answer

state law

question

The medical record is admitted into evidence as an exception to what rule?

answer

hearsay

question

The HIM professional may attend legal proceedings and testify as to which of the following?

answer

the authenticity of the medical record

question

A subpoena duces tecum compels the recipient to do which of the following:

answer

produce documents

question

A hospital employee destroyed a health record so that its contents, which would be damaging to the employee, could not be used at trial. In legal terms, the employee's action constitutes

answer

spoliation

question

Which is issued by the court if there is concern that information may be destroyed in cases of current of potential litigation?

answer

legal hold

question

A statement made to an attorney, psychologist or clergy that is protected from being revealed, even in court, is what type of communication?

answer

privileged

question

\"When determining whether or not evidence should be admissible in a court proceeding, the judge bases their decision by applying which of the following? a) best evidence rule b) hearsay exception c) business records exception d) all of the above

answer

d) all of the above

question

When determining whether or not health records are privileged, the HIM professional should refer to which of the following?

answer

state statutes

question

Which is not an area that describes a difference between electronic and paper records?

answer

confidentiality

question

Which of the following employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed?

answer

computer forensics

question

During a hearing to determine Worker's Compensation benefits for Tom Wilder, Mr. Wilder's medical records from Dr. Loop's office revealed that Mr. Wilder is HIV+. This information had been entered into Mr. Wilder's chart erroneously and was information about another patient. Mr. Wilder is not HIV+. Mr. Wilder filed a defamation lawsuit against Dr. Loop and his physician practice. What will be the most likely outcome?

answer

No defamation liability because of the absolute privilege defense

question

The most likely successful cause of action resulting from intentional touching by a healthcare provider, without the patient's consent, is:

answer

battery

question

Which elements must be present in order for damages in a negligence action to be awarded?

answer

Injury, duty of care, breach of duty, causation

question

An environmental service employee of the hospital was called to the vascular surgery floor to clean the floor where a bag of KCI (potassium chloride) had spilled. After cleaning the floor, the employee failed to place any signs advising others of a wet floor. Mrs. Jones, a hospital visitor, fell on the wet floor and injured her back. She incurred medical expenses of $560 and lost wages in the amount of $1,000. She brought suit and the jury awarded her $1,560, representing reimbursement of the medical expenses and lost wages. What is this amount considered?

answer

economic compensatory damages

question

What is the term used to denote a cause of action when a physician fails to perform with reasonable skill and care?

answer

negligence

question

Assault and battery falls under the category of:

answer

intentional tort

question

Johnny Doolittle died as a result of an adverse reaction to a medication administered during surgery at Getwell Hospital, a Joint Commission-accredited facility. The hospital had consistently failed to enforce Joint Commission standards requiring the presence of a complete history and physical exam on the patient's chart prior to surgery. Because of the absence of a history and phsycial exam on the patient's chart and the information it would have contained regarding drug allergies, the hospital may be found to have committed:

answer

breach of duty

question

Conduct which places a person in reasonable apprehension of being touched in a manner that is insulting, provoking, or physically injurious is called:

answer

assault

question

A patient is treated in the Emergency Room for severe laceration of the foot. The patient is given written instruction by the phsycian to have the sutures removed in three days, which the patient fails to do. A severe infection ensues resulting in permanent damage to the patient's foot. The patient sues the surgeon for negligence and the surgeon uses the ER record to prove what type of defense?

answer

contributory negligence

question

The statue of limitations generally refers to:

answer

period of time within which a lawsuit must be brought

question

All of the following must be proved to collect damages in a negligence suit except:

answer

unlawful touching

question

What type of damages have been primary targets of tort reform legislation?

answer

noneconomic compensatory damages

question

During hospitalization Mrs. Jones went into shock. Hot water bags and other restoratives were ordered by the attending physician. Because the temperature of the hot water bags was too high, and not checked by the nurse, Mrs. Jones suffered painful and permanent injuries. In this instance who may be sued under the doctrine of respondeat superior?

answer

hospital

question

\"What are the two types of causation necessary to meet the \"\"causation\"\" element of negligence?\"

answer

actual and proximate

question

A patient sued Dr. Smith for negligent care. Dr. Smith produced evidence showing that the patient's poor medical outcome was due to the patient's failure to follow his treatment plan and to take his prescribed medications. If a court refuses to grant the patient any money damages because the patient's action contributed to the harm what defense has the court applied to its final judgment?

answer

contributory negligence

question

In the above situation if the court allows the plaintiff to only recover damages to the extent he/she was not responsible for the harm, what defense has the court applied to its final judgment?

answer

comparative negligence

question

Which of the following terms denotes the suspension of the start of a statute of limitations clock?

answer

tolling

question

Proximate cause is based on whether or not it was ____ that the defendant's breach of duty would cause the harm.

answer

forseeable

question

Which of the following is not a valid defense to a claim of defamation?

answer

information was spoken only; it was not in writing

question

A scalpel was left in a patient during an exploratory laparotomy. Additional surgery was required to remove the scalpel. Based on these facts, which one of the following rules applies?

answer

res ipsa loquitur

question

The burden of proof usually falls upon the plaintiff, except in cases which apply the principle of:

answer

res ipsa loquitur

question

What is the term used to denote the liability of an employer for the acts of its employees?

answer

respondent superior

question

\"Intentional confinement of an individual against his or her wishes may be legally defensible if: a) a mentally ill patient is a danger to self and others b) an individual has a dangerous contagious disease c) both a and b d) intentional confinement is never legally defensible

answer

c) both a and b

question

If a hospital is held liable in its own right for the harm that the physicians on its medical staff cause to a patient, the legal theory being applied is:

answer

respondeat superior

question

\"Although a cause of action for false imprisionment may result if a hospital retains a patient against the patient's willis a) is over 65 b) a danger to himself or others c) has not paid his medical bill d) has a highly contagious disease

answer

b) a danger to himself or others c) has not paid his medical bill

question

In general, the Uniform Photographic Copies of Business and Public Records as Evidence Act does which of the following?

answer

allows record reproductions to be admitted as evidence

question

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

answer

designated record set is defined by HIPAA legislation

question

Destruction of health records

answer

may be a prudent business practice

question

The legal health record

answer

is the record that is disclosed upon request

question

The legal health record must meet standards 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 it back to insure order is correct

question

Which of the following exemplifies an acceptable patient record entry?

answer

patient articulated pain level as a 6

question

Staff disagreements within the health record should be

answer

avoided

question

Legally, which 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

A late entry into a 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 EHR documentation is more susceptible than the paper health record to which of the following functions?

answer

cut and paste

question

Record maintenance and content requirements are established in part by

answer

Department of Health and Human Services, Joint Commission, Centers for Medicare and Medicaid Services

question

What Act served to make electronic transactions as enforceable as paper transactions?

answer

Uniform Electronic Transactions Act

question

A countersignature

answer

signifies review and evaluation of the first provider's entry

question

An error in a paper health record should be

answer

crossed out so that it can be seen but not relied on

question

A personal health record

answer

may be housed in a system that a provider owns and controls

question

A physician who performs a surgical procedure on a patient without obtaining the patient's consent may be liable for

answer

battery

question

Consent that is conveyed through spoken or written words is

answer

express

question

Consent that is conveyed through a person's conduct is

answer

implied

question

If an individual is in an emergency condition and does not have capacity to communicate consent

answer

consent is implied by law

question

A patient signs a consent form, authorizing hospital staff to perform interventions necessary for overall medical care. This consent is

answer

general

question

Informed consent requires informing the patient of all of the following except

answer

hospital charges versus amount covered by insurance

question

Laws that require drivers to consent to blood alcohol tests with penalties for refusal, probably exist to

answer

protect the public

question

Under the Common Rule, informed consent for human subjects in research studies may be waived if

answer

the institutional review board approves a waiver

question

GINA applies to

answer

health insurers, group health plans, employers with 15 or more employees

question

GINA

answer

prohibits discrimination based on genetic information

question

Under HIPAA, compound authorizations

answer

combine informed consent with authorization for use and disclosure of a research subject's health information

question

Advance directives

answer

provide a way for individuals to communicate their healthcare wishes before they become incapacitated

question

If it is not durable, a power of attorney if effective

answer

only when the principal has capacity

question

A living will

answer

expresses an individuals healthcare wishes when specific health conditions exist

question

A do not resuscitate order

answer

is a type of advance directive, is used only in emergency situations, may be revoked at any time

question

The Uniform Anatomical Gift Act

answer

promotes consistency among state laws, provides suggested standards for all aspects of organ donation, includes an opt-in system for organ donation

question

When a competent adult refuses to consent to lifesaving treatment, the two competing sets of interest that come into play are the individual's privacy interest and

answer

the governments interest in protecting and preserving human life

question

In In Re Quinlan, the court held that

answer

an incompetent individual has a right of privacy to terminate treatment

question

In the Cruzan case, the Missouri Supreme Court held that no one can make end-of-life decisions on behalf of an incompetent person without

answer

clear and convincing evidence

question

The Uniform Health-Care Decisions Act

answer

provides an additional option to creating advance directives

question

Emancipated minors are defined as those who have

answer

been afforded legal status as an adult

question

State laws most likely permit a minor to consent on their own behalf for which of the following conditions?

answer

alcohol addiction

question

Frances has been experiencing abdominal pain. Removal of her gallbladder has been recommended. Who is responsible to obtain Frances' informed consent?

answer

the physician who performed the surgery

question

What is an artificial being created per state statutory authority

answer

corporation

question

What characterizes a corporation

answer

it is separate from its owners or incorporators, it can sue or be sued, it can continue to exist despite an owner's death

question

Piercing the corporate veil refers to

answer

holding corporation owners liable for bad acts

question

A non-for-profit corporation may

answer

pay reasonable salaries to its employees

question

Bylaws

answer

are the internal rules of an organization

question

A not-for-profit corporation that is formed for a charitable purpose

answer

must meet IRS established criteria to be tax-exempt

question

Fiduciary duty includes

answer

duty of loyalty and duty of responsibility

question

Ultra vires acts are those that

answer

exceed a corporation's powers

question

General Hospital is a 1,000 bed facility. Mercy Hospital is a 100 bed hospital. They join to form one corporation which is named General Hospital. The restructuring that has most likely occurred is a

answer

merger

question

Contracts

answer

must contain an offer and acceptance

question

A physician has been found to have breached his contract with a patient through abandonment. As a remedy, the court may order

answer

compensatory damages

question

A term used to describe standard contract terms is

answer

warranty

question

In the \"learned intermediary\" defense used by HIT vendors, who is the learned intermediary

answer

physician

question

Which of the following is not a federal antitrust law?

answer

HIPAA

question

When two or more entities at different levels in a distribution chain act together to restrain trade, this is

answer

vertical restraint of trade

question

Which offers both civil and criminal penalties?

answer

Sherman Act

question

Which actions related to the medical staff might raise antitrust issues

answer

excluding entire classes of practitioners from medical staff membership

question

Economic credentialing

answer

may be associated with physicians who have an ownership in competing hospitals, may be based on perceived loss of loyalty by a physician, may be associated with a review of a physician's volume of cases

question

Noncompete agreements

answer

might violate antitrust laws

question

Which of the following characterizes a join venture

answer

created for a specific purpose and designed to have a limited lifespan

question

A publicly held corporation

answer

generally has thousands of shareholders

question

Which of the following describes a responsibility of corporation's governing board members

answer

appointing medical staff members

question

Which is not a required element for piercing the corporate veil?

answer

corporation of a not-for-profit entity

question

Challenges to tax-exempt corporations operating with charitable purpose include

answer

aggressive billing practices, insufficient charity care provided, inflated billing practices toward the uninsured

question

What is an artificial being created per state statutory authority

answer

corporation

question

What characterizes a corporation

answer

it is separate from its owners or incorporators, it can sue or be sued, it can continue to exist despite an owner's death

question

Piercing the corporate veil refers to

answer

holding corporation owners liable for bad acts

question

A non-for-profit corporation may

answer

pay reasonable salaries to its employees

question

Bylaws

answer

are the internal rules of an organization

question

A not-for-profit corporation that is formed for a charitable purpose

answer

must meet IRS established criteria to be tax-exempt

question

Fiduciary duty includes

answer

duty of loyalty and duty of responsibility

question

Ultra vires acts are those that

answer

exceed a corporation's powers

question

General Hospital is a 1,000 bed facility. Mercy Hospital is a 100 bed hospital. They join to form one corporation which is named General Hospital. The restructuring that has most likely occurred is a

answer

merger

question

Contracts

answer

must contain an offer and acceptance

question

A physician has been found to have breached his contract with a patient through abandonment. As a remedy, the court may order

answer

compensatory damages

question

A term used to describe standard contract terms is

answer

warranty

question

In the \"learned intermediary\" defense used by HIT vendors, who is the learned intermediary

answer

physician

question

Which of the following is not a federal antitrust law?

answer

HIPAA

question

When two or more entities at different levels in a distribution chain act together to restrain trade, this is

answer

vertical restraint of trade

question

Which offers both civil and criminal penalties?

answer

Sherman Act

question

Which actions related to the medical staff might raise antitrust issues

answer

excluding entire classes of practitioners from medical staff membership

question

Economic credentialing

answer

may be associated with physicians who have an ownership in competing hospitals, may be based on perceived loss of loyalty by a physician, may be associated with a review of a physician's volume of cases

question

Noncompete agreements

answer

might violate antitrust laws

question

Which of the following characterizes a join venture

answer

created for a specific purpose and designed to have a limited lifespan

question

A publicly held corporation

answer

generally has thousands of shareholders

question

Which of the following describes a responsibility of corporation's governing board members

answer

appointing medical staff members

question

Which is not a required element for piercing the corporate veil?

answer

corporation of a not-for-profit entity

question

Challenges to tax-exempt corporations operating with charitable purpose include

answer

aggressive billing practices, insufficient charity care provided, inflated billing practices toward the uninsured

question

Discovery method that includes written questions that must be answered by potential witness

answer

interrogatories

question

state appellate court will hear a case dealing with an injury to a patient if the attorney appealing the case can prove

answer

an error of law occurred

question

when served with a court order directing the release of health records, an individual

answer

must comply with it

question

defendent fails to respond to a plaintiffs complaint, this may result in

answer

default judgment

question

following step should NOT be in health info dept procedure for preparing records in response to a subpoena

answer

remove pages containing detrimental info

question

from an evidentiary standpoint, incident reports

answer

should not be placed in the patients health record

question

medical record of kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wishes to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the

answer

business records exception

question

E-discovery rules are amendments to the _____ and were created in response to the tremendous volume of evidence, maintained in electronic format that is pertinent to lawsuits

answer

federal rules of civil procedure

question

Relevant eveidence

answer

tends to make the existance of a fact more or less probable

question

authentication of the record refers to

answer

establishment of its trustworthiness

question

environmental service employee of the hosp was called to the vascular surgery floor to clean the floor where a bag of potassium chloride spilled. after cleaning the floor, the employee failed to place a sign about a wet floor. mrs jones, a hosp visitor fell on the floor and got hurt. she incurred med expense of $560. and lost wages of $1000. she brought suit and the jury awarded her $1560, representing reimbursement of the med expenses and lost wages, plus $10k for jurors perceived recklessness on the part of the hosp. what is the $10k considered?

answer

punitive damages

question

HIM professional may attend leagal proceedings and testify as to

answer

authenticity of patients health record

question

hosp employee destroyed a health record so that its contents-which would be damaging to the employee- could not be used at trial. In legal terms the employees action constitutes

answer

spoliation

question

plaintiffs attorney has filed a state-law complaint in fed court. this is an error of what nature?

answer

procedural law

question

gloria kramer files a med malpractice lawsuit against dr johnson alleging that he committed negligence in the treatment of her diabetes. ms. kramers attorney insists that dr johnson can't speak about her med diagnosis becuase of physician-patient privilege. ms. kramers attorney

answer

is incorrect because she placed her med condition at issue

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per the theory of physician/patient privilege, the right to waive the confidentiality of med info belongs to the

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patient

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metadata is

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info about an electronic record

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patient-privilege is defined by

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state law

question

subpoena duces tecum compels the recipient to

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bring records to a legal proceeding

question

defendant does not pay the damages awarded against her in a lawsuit. the court may order the seizure of a portion of her monthly wages to satisfy the judgment in an action called

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garnishment

question

if a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be followed in determining the case is

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stare decisis

question

collection of fed statutes is found in a

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code

question

concept of confidentiality applies to

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all data and info systems automated paper and verbal communications clinical, financial and business records

question

what is the intermediate court in the tiered structure of the state court system in nearly every state?

answer

appellate court

question

appellate courts are called ________ in federal court system

answer

circuit courts

question

regulations written by the state dept of health of US dept of health and human svcs are examples of

answer

administrative law

question

what law(s) involve govt as one of the parties?

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public law and criminal law

question

principle of law that serves as a guide in similar subsequent cases is called

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precedent

question

when a dispute is submitted to disinterested 3rd party and the 3rd party settles the case, this is

answer

arbitration

question

In the US, both the federal and state court systems us a _____ tier approach

answer

three

question

judicial decision may be based on the following types of actions

answer

disputes between individuals challenges to the constitutionality of a statute

question

legislative act passed by congress is an example of

answer

statutory law

question

what is the legal term used to define the protection of health info in the patient-provider relationship

answer

confidentiality

question

law based on judicial decision is called

answer

common law

question

mary has gone to her dr to discuss a med condition, what legal term best describes the type of communication that has occured between them

answer

priviledged communication

question

health info privacy has been established in all but one way

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constitutional right

question

custodian of health records refers to the individual within an organization is responsible for what action

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authorized to certify records supervise the inspection and copying of record testifies to the authenticity of records

question

term used to describe a patient has the right to maintain control over certain personal info is referred to as

answer

privacy

question

what is the term used to physical and electronic protection of health information

answer

security

question

what is also known as case law

answer

judicial law

question

party that presents evidence to disprove or disprove wrongdoing is the

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defendant

question

criminal law is a type of

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public law

question

US code is

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statutory law

question

under the concept of stare decisis

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lower courts look to higher courts

question

fed court has legal control over cases involving federal statutes. this legal contol is referred to as

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jurisdiction

question

this legal doctrine limits excessive litigation by prohibiting subsequent lawsuits about the same matter and involving the same parties once a decision has been made and all appeals have been exhausted

answer

res judicata

question

one restriction involving diversity jurisdiction is

answer

no plaintiff can be from the same state as any of the defendants

question

what court is the lowest court in the tiered structure of the state court system in nearly every state

answer

trial court

question

legislative act passed by congress is an example of

answer

statutory law

question

centers for disease control and prevention is located in the US

answer

dept of health & human services

question

federal court system, appellate courts are called

answer

circuit courts

question

legal matter was tried at the district court level and appealed to a fed appellate court. the case was appealed to the US supreme court, which declined to hear it. when the supreme court declined the case it

answer

denied cert

question

med malpractice appeal brought by carol agains mercy hosp has just concluded. the court reached a decision in favor of the hosp. the courts written determination that outlined the facts of the case and the legal theories followed to reach its outcome is an

answer

opinion

question

federal trial courts are called

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district courts

question

lawsuit is brought against a govt in

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court of claims

question

appellate courts hear appeals on final judgments of

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trial court decisions

question

US congress follows the model

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bicameral

question

agency that is heavily involved in combating medicare & medicaid fraud is

answer

inspector general for health & human services

question

in general, if virginia and texas laws conflict

answer

each state follows its own law

question

one or more advantages of mediation over utilizing the court system to resolve a dispute are

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time saving cost saving increase privacy

question

deeming authority has been granted by the US dept of HHS to the

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american osteopathic assoc

question

authority of TJC is mostequivalent to that of the

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commission of accreditation of rehab facilities

question

health information privacy protection has been established in court decisions, federal laws, state laws, but not

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constitutional rights

question

who owns the health record

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provider who generated the info

question

what is the term used most often to describe the indiv within an org who is responsible for protecting health info in conjuction with the court system

answer

custodian of record

question

many laws address patient privacy and confidentially. what other resourses address the providers resp for keeping health info private

answer

professional code of ethics

question

when someone is identified as an information steward, the indiv is resp for what activities

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integrity of electronic health record protecting loss or destruction of electroinic health record security of record

question

courts rules that guide a lawsuit from beginging to end is

answer

procedural law

question

class action lawsuits often involve

answer

groups of consumers against large entities

question

legal proceedings that accompany a lawsuit is

answer

litigation

question

dr huffman has been sued by a patient, he brings in the manufacturer as defendant. this process is

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joinder

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service is

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notification of a lawsuit

question

process that allows evidence to be used in a court of law and considered by a jury is

answer

admissibility

question

mary has been deposed via a subpoena duces tecum. as the HIM director of hosp, she will bring the health record of a patient. her role is

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authenticate the records validity

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court orders for the production of records

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do not require patient authorization

question

subpoena

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may be issued by a partys attorney

question

forma, written objections to subpeonas are often made in a

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motion to quash

question

when removing a health record in response to a subpoena duce tecum or a court order, what should be completed

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an index of contents

question

bench trial refers to a trial

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without a jury

question

excusal of a juror without a stated reason is

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peremptory challenge

question

the burdon of proof in which a plaintiff must prove that it was more likely than not that each element of a case was met is

answer

compensatory damages

question

actual damages, which compensate a plaintiff for losses incurred are

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compensatory

question

what type of damage is collected by implementing monetary caps to couteract lavish jury awards

answer

non-economic compensatory

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party who appeals a trial court decision is

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appellant

question

if a plaintiff incurs $30k in damages realted to a medical expense and lost wages, what are these

answer

economic compensatory damages

question

mrs black sued mr brown for failing to return the clock. mr brown ignured mrs blacks lawsuit and she won a judgment of $1000. the court encumbered mr browns property so that when he tried to sell it 3 years later, he was unable to take any profit from the sale until mrs black was first pait this is

answer

judgment lien

question

when mr brown ignored mrs blacks lawsuit she won the case under what legal theory

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default judgment

question

dr howard is called to testify in a med malpractice case against dr hale. he testifies that base on his expertise of the subject matter. dr dale didnt commit med malpractice. dr howard is a/an

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expert witness

question

when an indiv represents herself as her own attorney she is

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acting pro se

question

when a patient discovers that a sponge has been left in his abdomen, the patient brings a lawsuit. to do this the patient must document and serve his allegations to the surgeon in a legal document called

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complaint

question

lawsuit has been filed against a hosp for bodily injuries allegedly suffered by a patient. legal counsel for the hosp believes the injuries are exaggerated. he used what discovery method to determine the true extent of the injuries

answer

physical exam

question

whether or not information may be introduced formally into evidence at trial is called

answer

admissibility

question

per the theory of physician/patient privilege, the right to waive the confidentiality of medical info belongs to the

answer

patient

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metadata is

answer

info about electronic record

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legal hold

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is issued by a court if there is concern about destruction of info during litigation

question

authenticiation of a record refers to

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establishment of its baseline trustworthiness

question

health record is representative of what type of evidence

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demonstrative evidence

question

best evidence rule

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permits copies to be substituted in certain cercumstances

question

from an evidentiary standpoint, incident reports

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should not be placed in a patients health record

question

during a trial to determiine wheither dr smith was liable for medical malpractice, dr smith testified in his own defense. legally, dr smiths testimony was

answer

direct evidence

question

relevant evidence

answer

tends to make theexistence of a fact more or less probable

question

patient-provider privelege is defined by

answer

state law

question

medical record is admitted into evidence as an exception to what rule

answer

hearsay

question

HIM professional may attend legal proceedings and testify to

answer

authenticate the health record

question

subpoena duces tecum compels the recipient to NOT do;

answer

serve on a jury answer a complaint produce documents

question

what is issued by the court if there is concern that info may be destroyed iin cases of current or potential litigation

answer

legal hold

question

statement made to an attorney, psychologist or clergy that is protected from being revealed even in court is what type of communication

answer

privileged

question

when determining whether or not evidence should be admissible in a court proceeding, the judge bases his discision on

answer

best evidence rule hearsay exception business records exception

question

when determining whether or not health records are privileged, the HIM professional should refer to

answer

state statutes

question

what is not a difference between electronic and paper records

answer

confidentiality

question

what employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed

answer

computer forensics

question

during hospitalization, mrs jones went into shock. hot water bags and other restoratives were ordered by attending physician. because the temp of water bags was too high, and not checked by the nurse, mrs jones suffered painful and permanent injuries. in this instance who may be sued under the doctrine of respondent superior

answer

hospital

question

what type of damages have been primary targets of tort reform legislation

answer

non-economic compensatory damages

question

what is the term to denote a cause of action when a physician fails to perform with reasonable skill and care

answer

negligence

question

if the court allows the plaintiff to only recover damgages to the extent (percentage) he was responsible for harm, what defense has the court applied to its final judgment

answer

comparative negligence

question

scalpal was left in a ptient during an exploratory aparotomy. additional surgery was required to remove the scalpel. based on the facts, what rule applies

answer

res ipse loquitur

question

unlawful intusion on an individual is considered

answer

invasion of privacy

question

burden of proof usually falls upon the plaintiff, except in case which apply the principle of

answer

res ipsa loquitur

question

what term denotes the suspension of the start of the statute of limitations clock

answer

tolling

question

the most likely cause of action from intentional touching by a healthcare provider, without patients consent is

answer

battery

question

conduct which places a person in reasonable apprehension of being touched in a manner that is insulting , provoking or physically injurious is

answer

assault

question

patient sued for negligent care. dr smith produced evidence showing that the patients poor medical outcome was due to the patients failure to follow his treatment plan and take the meds. if a court refuses to grant the patient any money damages because the patients actions contributed to the harm, what defense has the court applied to its final judgment

answer

contributory negligence

question

statute of limitations generally refers to

answer

period of time within which a lawsuit must be brought

question

patient is treated in er for laceration of the foot. the patient is given written instructions by the dr to have the sutures out in 3 days which the patient fails to do. an infection ensues resulting in permanent damage to the foot. the patient sues the surgeon for negligence and the surgeon uses the er record to prove what type of defense

answer

contibutory negiligence

question

what is a valid defense to a claim of defamation

answer

info was not published to a third party info was spoken only , it was not in writing communication was privileged because it was an issue of public safety

question

assault and battery fall under the category of

answer

intentional tort

question

what elements must be present in order for damages in a negligence action be awarded

answer

injury, duty to care, breach of duty, causation

question

proximate cause is based on whether or not it was ___ that the defendants breach of duty ould cause harm

answer

forseeable

question

johnny died as a result of an adverse reaction to meds given during surgery at mercy hosp, a joint commission accredited facility. the hosp had consistently failed to enforce TJC stancdards requiring the presence of a complete history and physical exam on the patients chart prior to surgery. because of the absence of a history and physical exam on the patients chart and the info it would have contained regarding drug allergies, the hosp may be found to have committed

answer

breach of duty

question

during a hearing to determint workers comp benefits for tom, his med records from dr loop revealed that tom is HIV+. this info had been entered into toms chart erroneously and was informormation about another patient. Tom is not HIV+. Tom filed a defamation lawsuit against dr loop and his physician practice. what will be the most likey outcome

answer

no defamatiion on liability because of the absolute privlege defense

question

most likely successful cause of action resulting from intentional touching by a healthcare provider w/o patients consent is

answer

batter

question

which elements must be present in order for damages in a negligence action to be awarded

answer

injury, duty of care, breach of duty, causation

question

assault and battery falls under the category of

answer

intentional tort

question

what type of damages have been primary targets of tort reform legislation

answer

noneconomic compensatory damages

question

what are the 2 types of causation necesary to meet the causation element of negligence

answer

actual and proximate

question

if a court allows the plaintiff to only recover damages to the extent he was not responsible for the harm, what defense has the court applied to its final judgement

answer

comparative negligence

question

intentional confinement of an individual against his wishes may be legally defensible if

answer

a mentally ill patient is a danger to self and others an indiv has a dangerous contagious disease

question

although a couse of action for false impreonment may result if a hosp retains a patient against their will, a hosp may be protected from liability if the patient

answer

is a danger to himself or others has a highly contagious disease

question

hosp is held liable in its own right for the harm that the physicians on its medical staff couase to a patient, the legal theory being applied is

answer

respondeat superior

question

what is an artificial being created per state statutory authority

answer

corporation

question

what characterizes a corporation

answer

it is separate from its owners or incorporators it can sue or be sued it can continue to exist despite an owners death

question

piercing the corporate veil refers to

answer

holding corporation owners liable for bad acts

question

not for profit corp may

answer

pay reasonable salaries to its employees

question

bylaws

answer

are the internal rules of an organization

question

not for profit corp that is formed for a charitable purpose

answer

must meet irs established criteria to be tax exempt

question

fiduciarty duty includes

answer

duty of loyalty duty of responsibility

question

ultra vires acts are those that

answer

exceed a corporations powers

question

general hosp is a 1000 bed facility. mercy hosp is a 100 bed facility. they join to form one corp, which is named general hosp. the restructuring that has most likely occured is a

answer

acquisition

question

contracts

answer

must contain an offer and acceptance

question

physician has been found to have breached his contract with a patient through abandonment. as a remedy, the court may order the following

answer

compensatory damages

question

term used to describe standard contract terms is

answer

boilerplate

question

learned intermediary defense used by HIT vendors, who is the learned intermediary

answer

physician

question

what is not a federal antitrust law

answer

HIPPA

question

What are federal antitrust laws

answer

sherman act clayton act federal trade commission act

question

when two or more entities at different levels in a distribution chain act together to restrain trade, this is

answer

vertical restraint of trade

question

what act offers both civil and criminal penalties

answer

sherman act

question

what actions related to the medical staff might raise antitrust issues

answer

excluding entire class of practitioners from medical staff membership

question

economic credentialing

answer

may be associated with physicians who have an ownership in competing hospitals may be based on a perceived loss of loyalty by a physician may be associated with a review of a physicans volume of cases

question

noncompete agreements

answer

might violate antitrust law

question

what is NOT a defense for nonperformance of a contract

answer

specific performance

question

what is a defense for nonperformance of a contract

answer

fraud mistake of fact duress

question

what characterizes a joint venture

answer

created for a specific purpose designed to have a limited lifespan

question

publicly held corp

answer

generally has thousands of shareholders

question

what describes a responsibility of corps governing board members

answer

appointing medical staff members

question

what is NOT a required element for piercing the corporate veil

answer

corp is a not for profit entity

question

what is a required element for pierceing the corporate veil

answer

complete domination of the corp by its owners control by owners was used to perpetrate a wrongful act corp control was the proximate cause of injury

question

challenges to tax exempt corps operating with a charitable purpose inclue

answer

aggressive billing practices insufficient charity care provided inflated billing practices toward the uninsured

question

legal health record must meet requirements as defined by

answer

federal regulations state laws accreditation body standards

question

once the paper has been converted to microfild or scanned into electronic record, the info cannot be used as evidence

answer

false

question

gold of E-sign legislation was to

answer

give electronic signatures increased legal standing

question

mary is 95, while an inpatient at general hosp she agrees she doesnt want to be resuscitated if she would have a cardiac arrest. she signs a form and the physician documents it in the record this is

answer

DNR order

question

janice arrives at her physicians office for her appt and pays her office visit co-pay. her dr examines her. based on these facts janices consent is

answer

implied

question

auto-authentication

answer

contradicts basic authentication standards

question

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 or most important use of patient health info

answer

patient care

question

dr harvey has changed a piece of datea in the patients record. the info that tracks this change and enables a jury to see this change in a med malpractice action is called

answer

metadata

question

printing paper documents for an EHR system

answer

creates legal challenges asto which document is the source of truth

question

advance directive is used to direct individuals health care wishes in the event of

answer

patient incapacitation

question

late entry into the health record should

answer

be identified as a late entry

question

record maintenance and content requiremenet are established in part by

answer

NY state doh TJC CMS

question

patient self determiniation act requires health care providers to

answer

inform patients of their right to creat advance directives document the presence or absence of advanced directives in the patient health record

question

abbreviations in the health record

answer

should have only one meaning

question

what is most likely to happen to the health records of a physicians patient when a physician leaves an office practice

answer

retained by the practice

question

mary is contemplating triple bypass surgery. informed consent by her surgeon would typically contain what elements

answer

purpose of the proposed procedure risks associated with the procedure non invasive treatment alternatives

question

staff disagreements within the health record should be

answer

avoided

question

mrs bolton is an angry patient who resents her dr \"bossing her around\". she refuses to take meds the nurse bring to her pursuant to drs orders and is verbally abusive to patient care assts. what is appropriate way to document her behavior in the record

answer

noncompliant and hostile toward staff

question

emergencies are a exception to the consent requrement for

answer

adults and minors

question

mrs davis is preparing to undergo hernia repair sugery . who should obtain the informed consent

answer

the surgeon doing the surgery

question

changes to health record entries

answer

are indicative of negligent care

question

legally, what is most important in determing the length of time that a hosp must retain records

answer

statute of limitations

question

uniform health care decision acts ranks next of kin for adults in what order for medical decision making

answer

spouse, adult child, parent, adult sibling

question

Johnny is 12 and his parents are divorced. in order for johnny to receive medical treatment, who can consent

answer

one parent must consent

question

physician who performs a surgical procedure on a patient without obtaing consent may be liable for

answer

battery

question

consent that is conveyed through spken or written words is

answer

express

question

consent that is conveyed through a persons conduct is

answer

implied

question

indiv is in an emergency condition and does not have capacity to communicate consent

answer

consent is implied by law

question

patient signs a consent form ,authorizing hsop staff to perform interventions necessary for overall medical care. this consent is

answer

general

question

informed consent requires informing the patient of

answer

nature and purpose of proposed treatment risks and benefits of proposed treatment alternatives to proposed treatment

question

proposed med intervention is related to a research study

answer

institutional review board approval is required

question

laws that require drivers to consent to blood alcohol tests, with penalties for refusal, probably exist to

answer

protect the public

question

under the common rule, informed consent for human subjects in research studies may be waived if

answer

the institutional review board approves a waiver

question

GINA applies to

answer

health insurers group health plans employers with 15 or more employees

question

GINA

answer

prohibits discrimination based on genetic info

question

under HIPAA, compound authorizations

answer

combine informed consent with authorization for use and disclosure of a research subjects health info

question

advance directives

answer

provide a way for physicians to ensure that life saving treatment is given, regardless of an indivuals wishes

question

if it is not durable, a POA is effective

answer

only when the principle has capacity

question

living will

answer

expresses an indiv healthcare wishes when specific health conditions exist

question

do not resuscitate order

answer

is a type of advance directive is used only in emergency situations may be revoked at any time

question

uniform anatomical gift act

answer

promotes consistency among state laws provides suggested standards for all aspects of organ donation includes an opt in system for organ donation

question

when a competent adult refuses to consent to lifesaving treatment , the two competing sets of interest that come into play are the indiv privacy interest and

answer

the governments interest in protecting and preserving human life

question

re quinlan the court held that

answer

an incompetent indiv has a right of privacy to terminate treatment

question

cruzan case, the missouri supreme court held that no one can make end of life choices on behalf of an incompetent person w/o

answer

clear and convincing evidence

question

end of life controversy in the terri schiavo case included

answer

a question about teh authority of legislative bodies to intervene in judicial matters

question

uniform health care decisions act

answer

provides an additional option to creating advance directives

question

emancipated minors are defined as those who have

answer

been afforded legal status as an adult

question

state laws most likely permit a monir to consent on their own behalf for

answer

alcohol addiction

question

frances has been experience abdominal pain. removal of her gallbladder has been recommended. who is resp to obtain her informed consent

answer

the physician who will perform the surger

question

uniform photographic copies of business and public records as evidence act does what

answer

allows record reproductions to be admited as evidence

question

legal health record or designated record set is

answer

designated record set is defined by HIPAA legislation legal health recores is defined by the facility legal health record my not include all of the info in the designated record set

question

destruciton of health records

answer

may be a prudent business practice

question

legal health record

answer

is the record that is disclosed upon request

question

verbal orders by phone or in person are discouraged. in cases where verbal orders are necessary, what is the most effective method by which the risk of miscommunication can be lessened

answer

person receiving order should read it back to insure the order is correct

question

integrity referes to

answer

accuracy and completeness of info

question

authentication methods include

answer

handwritten signature rubber stamp signature electronic signature

question

integrity of EHR documentation is more susceptible that paper health record to what function

answer

cut and paste

question

who has ultimate legal responsibility for the quality of care rendered in a healthcare org

answer

governing body

question

what act served to make electronic transactions as enforeable as paper

answer

uniform electronic transactions act

question

countersignature

answer

signifies review and evaluation of the first providers entry

question

error in a paper health record should be

answer

crossed out so that it can be seen but not relied on

question

personal health record

answer

may be housed in a system that a provider owns and controls

question

Name three ways that the Health information privacy protection has been established.

answer

Court decisions, State laws, Federal laws

question

Mary Smith has gone to her doctor to discuss her current medical condition, what is the legal term that best describes the type of communication that has occurred between Mary and her physician?

answer

Privileged communication

question

The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as:

answer

Privacy

question

What is the legal term used to define the protection of health information in a patient-provider relationship?

answer

Confidentiality

question

What is the legal term used to describe the physical and electronic protection of health information?

answer

Secrity

question

The \"custodian of health records\" refers to the individual within an organization who is responsible for:

answer

Authorized to certify records, supervise inspections and copying of records, and testifies to authenticity of records

question

Who owns the health record?

answer

Provider who generated the information

question

What is the term used most often to describe the individual within an organization who is responsible for protecting health information in conjunction with the court system?

answer

Custodian of Record

question

If a healthcare provider is accused of breaching the privacy and confidentiality of a patient what resource may a patient rely on to substantiate the providers responsibility for keeping health information private?

answer

Professional Code of Ethics

question

The concept of confidentiality applies to:

answer

All data and information systems, automated, paper, and verbal communications, clinical, financial, and business records

question

Law based upon judicial decision is called:

answer

Common law

question

The collection of federal statutes is found in a:

answer

Code

question

Which type of law involves the government as one of its parties?

answer

Public and criminal

question

A legislative act passed by Congress is an example of:

answer

Statutory and administrative law

question

In general, if a South Carolina law and a North Carolina law conflict, whose law is follwed?

answer

Each state follows its own law

question

Judicial decisions may be based on what type of actions\"

answer

Disputes between individuals and challenges to the contitutionality of a statute

question

If a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be follwed in determining this case is:

answer

Stare decisis

question

What is the name of the intermediate court in the tiered structure of the state court system in nearly every state?

answer

Appellate court

question

Appellate courts draft:

answer

Opinions

question

In the United States, both the Federal and the State court systems use the _______-tier approach.

answer

three

question

Statutory law derives from which branch of government?

answer

Legislative

question

Regulations written by a state department of health or the U.S. Department of Health and Human Services are examples of:

answer

Administrative law

question

Of the following,CMS, NIH, IHS, and HHS, which occupies the highest hierarchial position?

answer

HHS

question

The collection of federal statutory law is:

answer

United States Code

question

Diversity jurisdiction refers to the ability to bring legal action in a:

answer

Federal district court

question

Appellate courts are called _____ in the federal court system.

answer

Circuit courts

question

When a dispute is submitted to a disinterested third party and the third party settles the case, this is called:

answer

Arbitration

question

A lawsuit has been filed by John Collins, a resident of VA, against a hospital in PA alleging the wrongful disclosure of a patients confidential information. This lawsuit could be filed in what type of court?

answer

Federal district court

question

One or more advantages of arbitration over utilizing the court system to resolve a dispute is/are:

answer

Time saving, cost saving, and increased privacy

question

Which laws are synonymous terms for court decisions?

answer

Case law, common law, and judicial law

question

This type of law consists of rules and regulations issued by agencies that implement statutory law.

answer

Administrative law

question

A principle of law that serves as a guide in similar subsequent cases is called:

answer

Precedent

question

Alternate dispute resolution is an acceptable option to resolving cases via the court system for what type cases?

answer

Civial and criminal cases

question

Confidentiality

answer

a legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure

question

Custodian of health records

answer

the person designated as responsible for the operational functions of the development and maintenance of the health record and who may certify through affidavit or testimony the normal business practices used to create and maintain the record

question

Electronic health record (EHR)

answer

a computerized record of health information and associated processes; an electronic record of health-related information on an individual that conforms to nationally recognized standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization

question

Hybrid health record

answer

a record that uses a combination of paper and electronic formats

question

Legal health record (LHR)

answer

the form of health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization's legal health record depending on how the organization defines it

question

Ownership

answer

in healthcare, the person to whom the health record belongs (traditionally, the healthcare provider)

question

Personal health record (PHR)

answer

an electronic or paper health record maintained and updated by an individual for himself or herself

question

Privacy

answer

the quality or state of being hidden from, or undisturbed by, the observation or activities of other people or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information

question

Security

answer

1. The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss; 2. The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems

question

Administrative law

answer

rules and regulations created by administrative agencies

question

Arbitration

answer

a form of alternative dispute resolution in which a dispute is submitted to a third party or panel of experts outside the judicial trial system

question

Case law

answer

the body of law that is created when, as the result of a dispute, a court renders a decision

question

Civil law

answer

noncriminal law

question

Common law

answer

the body of law (that is, judicial or case law) that is created when a court renders a decision as the result of a dispute

question

Conflict of laws

answer

an inconsistency between the laws of different states arising from a legal action that involves the territory of more than one jurisdiction

question

Criminal law

answer

a type of law in which the government is a party prosecuting an accused who has been charged with violation a criminal statute or regulation

question

Due process of law

answer

the guarantee provided under the Constitution and the Bill of Rights that laws will be reasonable and not arbitrary and allow for challenges to a law's content and substance

question

Executive branch

answer

the branch of government charged with enforcing laws, including the issuance of regulations by administrative agencies, with ultimate executive-branch power vested in the chief executive (the president of the United States on the federal level and the governor of each state at the state level)

question

Judicial law

answer

the body of law created as a result of court (judicial) decisions

question

Legislative branch

answer

the branch of government charged with enacting laws in the form of statutes through the Senate and House of Representatives

question

Mediation

answer

a form of alternative dispute resolution in which a dispute is submitted to a third party and the outcome is decided by agreement of the parties

question

Private law

answer

the branch of law concerned with the rules and principles that define rights and duties among people and among private businesses

question

Public law (PubL)

answer

the branch of law concerned with the federal, state, or local government and its relationship to individuals and business organizations; the most familiar form of public law is criminal law

question

Separation of powers

answer

among the three branches of federal and state governments, the authority of each is limited in order to inhibit the ability of any one branch of government to become autocratic

question

Stare decisis

answer

Latin for \"let the decision stand\"; a legal doctrine stating that local courts within a court system are bound to follow (apply) the decisions of higher courts in the same court system in order to determine the outcome of a case, as long as the fact pattern of the case in the higher court is similar to that of the current case

question

Statutory law

answer

law based on statutes, which are created by the legislative branch of the government (the House of Representatives and the Senate)

question

Admissibility

answer

Evidence that is allowed to be admitted in a court of law

question

Burden of Proof

answer

The task of sufficiently proving or establishing the requisite degree of belief for each element of a case; usually belongs to a plaintiff

question

Compensatory Damages

answer

Damages in which the plaintiff is compensated for losses incurred; actual damages

question

Complaint

answer

The document that is filed with a court in order to commence a lawsuit

question

Court order

answer

A document issued by a judge that compels certain actions, such as testimony or the production of documents such as health records

question

Defendant

answer

The individual or organization that is the object of the lawsuit, and against whom a lawsuit is brought; wrongdoer

question

Discoverability

answer

Limitations on the ability of parties to discover pretrial information held by another party

question

Interrogatories

answer

Discovery devices consisting of written questions given to a party, witness, or other person who has information needed in a legal case

question

Jury

answer

The fact-finding body that hears evidence given by the parties, if they testify, and other witnesses; observes presented by both sides; hears the opening statements and closing arguments of each side; and decides facts based on the perceived credibility of the evidence, but does not decide law

question

Lay witness

answer

An individual's testifying based on his or her own observations of the situation(s) that prompted the case at hand

question

Plaintiff

answer

The individual who initiates a lawsuit to enforce either his or her rights or another's obligations

question

Procedural law

answer

The court's rules that guide a lawsuit from the time it begins through completion, whether it culminates in a trial or ends with a settlement or dismissal

question

Respondent

answer

The party against whom a petition is filed on appeal

question

Trial

answer

The stage in a lawsuit after the pretrial phase if the parties do not negotiate a settlement and the case is not dismissed

question

Voir dire

answer

The process through which a jury is selected

question

Admissibility

answer

evidence that is allowed to be admitted in a court of law

question

Authenticated evidence

answer

evidence that appears to be relevant and has been shown to have a baseline authenticity or trustworthiness

question

Circumstantial evidence

answer

evidence that is not directly from an eyewitness or participant and requires some reasoning to prove a fact

question

Demonstrative evidence

answer

actual objects, pictures, models, and other devices that are supposedly intended to clarify the facts for the judge and jury

question

Direct evidence

answer

\"real, tangible or clear evidence of a fact, happening or thing that requires no thinking or consideration to prove its existence\" (ALM Media Properties 2012)

question

Discoverability

answer

limitations on the ability of parties to discover pretrial information held by another party

question

e-Discovery

answer

pretrial legal process used to describe the methods by which parties will obtain and vie electronically stored information

question

Hearsay

answer

a written or oral statement made outside of court that is offered in court as evidence

question

Legal hold

answer

a court order that suspends the processing or destruction of paper or electronic records; also known as a preservation order, preservation notice, or litigation hold.

question

Spoliation

answer

intentional destruction, mutilation, alteration, or concealment of information relevant to a legal proceeding

question

Compensatory damages

answer

damages in which the plaintiff is compensated for losses incurred; actual damages

question

Contributory negligence

answer

an individual's conduct contributed in part to the injury that the individual suffered

question

Corporate negligence

answer

a doctrine under which hospitals may be held liable in their own right

question

Damages

answer

monetary compensation awarded by a court to an individual injured in a civil action through the wrongful act of another party

question

Intentional torts

answer

torts that involve a deliberate or intentional act

question

Joint and several liability

answer

a principle that allows each defendant in a legal action to be held responsible for the entire amount of damages that a plaintiff is awarded, regardless of the defendant's degree of fault

question

Misfeasance

answer

relating to negligence or improper performance during an otherwise correct act

question

Noneconomic damages

answer

damages that are not monetary in nature; an issue targeted by tort reforms

question

Punitive damages

answer

damages that exceed compensatory damages and serve to punish the defendant(s)

question

Res ipsa loquitur

answer

Latin for \"the thing that speaks for itself\"; an exception to the plaintiff having the burden of proof in which the facts or circumstances accompanying an injury may raise a presumption, or at least permit an interference, of negligence on the part of the defendant or some other individual who is charged with negligence and the burden of proof is shifted to the defendant

question

Respondeat superior

answer

Latin for \"let the master answer\"; the doctrine under which a hospital holds itself responsible for the actions of its employees provided those individuals were acting within the scope of their employment or at the hospital's direction at the time of the activity in question.

question

Tort

answer

a civil wrong for which the law provides a remedy in the form of a lawsuit to recover damages

question

Tort law

answer

law that involves the right of an individual, corporation, or other legal entity to recover damages for a loss caused by the defendant (tortfeasor or wrongdoer)

question

Tort reform

answer

the variety of measures intended by legislatures to overhaul the justice system; with regard to medical malpractice, such reforms are intended to diminish the number of lawsuits and large jury verdicts, stabilize the market, and ultimately reduce premiums for physicians

question

advance directive

answer

a legal document that specifies an individual's healthcare wishes in the event that he or she has a temp. or permanent loss of competence

question

consent

answer

a patient's acknowledgement that he or she understands a proposed intervention, including that intervention's risks; benefits, and alternatives. 2. a patient's agreement that protected health information can be disclosed; the document that provides a record of the patient's consent.

question

durable power of attorney (DPOA)

answer

a power of attorney that remains in effect even after the principal is incapacitated; can be drafted to take effect only when the principal becomes incapacitated

question

Durable power of attorney for healthcare decisions (DPOA-HCD)

answer

a legal instrument through which a principal appoints an agent to make healthcare decisions on the principal;s behalf in the event the principal becomes incapacitated

question

express consent

answer

consent that is communicated through words, regardless of whether those words are written or spoken

question

general consent

answer

a form that covers routine diagnostic procedures and medical treatment by a hospital staff as well as other activites such as release of info for treatment purposes and disposal of human tissue and body fluids

question

good samaritan law

answer

state law or statute that protects healthcare providers from liablity for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident

question

implied consent

answer

consent for medical treatment that is communicated through a person's conduct or some other means besides words

question

informed consent

answer

a type of consent in which the patient should have a basic understanding of which medical procedures or tests may be performed as well

question

living will

answer

a document executed by a competent adult that express that individual's wishes to limit treatment measures when specific health related diagnoses or conditions exist

question

power of attorney (POA)

answer

a legal instrument used by a principal (person) to grant legal authority to one or more agents to make certain legal and financial decisions on behalf of the principal

question

therapeutic priviledge

answer

a doctrine that has historically allowed physicians to withhold information information from patients in limited circumstances..

question

uniform heatlh care decisions act (UHCDA)

answer

a model law created in 1993 that provides that an individual may give an oral or written instruction to a healthcare provider that remains in force even after the individual loses capacity, and suggest decision making priority for that individual's surrogates.

question

authentication

answer

verification of records validation therefore it is reliable and truthfulness as evidence;also a security mechanism to validate the identity of a user in an electronic format

question

authenticity

answer

the genuineness of a record, that is what it purports to be; information is authentic if proved to be immune from tamperng and corruption

question

completeness

answer

an element of a legally defensible record; the health record is not complete until all parts are assembled and the appropriate documents are authenticated according to medical staff bylaws

question

designated record set (DRS)

answer

a group of records maintained by or for a covered entity encompassing medical records and billing records about individuals and enrollment, payment, claims adjudication, and case or medcial management record systems maintained by or for a health plan used, in whole or in part , by or for the covered entity to make decisions about individuals

question

legal health record (LHR)

answer

the form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organizations legal health record varies depending on how the organization defines it

question

master patient index (MPI)

answer

a patient identifying directory that serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death

question

retention

answer

a mechanism for storing records, providing for timely retrieval, and establishing the length of time that various types of records will be retained by the healthcare organization

question

statutes of limitations

answer

a statutory enactment that places time limits on certain items

question

uniform electronic transactions Act

answer

federal statute that makes electronic transactions as enforceable as paper transactions, removing barriers to electronic commerce and increasing trust associated with electronioc business transactions

question

affiliated covered entities

answer

legally separate covered entities, affliated by common ownership or control; for purpose of the Privacy Rule, these legally separate entities may refer to themselves as a single covered entity

question

covered entities

answer

persons or organizations that must comply ith the HIPPA Privacy and security rules; include healthcare providers, health plans, and healthcare clearinghouses

question

deidentified information

answer

information from which personal characteristics have been stripped and that, as a result, neither identifies or nor provides a reasonable basis to believe it could identify an individual.

question

health information technology for economic and clinical health act (HITECH)

answer

federal legislation that was passed as a portion of the Amercan Recovery and Reinvestment act; contains changes to the HIPAA Privacy rule

question

notice of practices

answer

A statement issued by a healthcare organization that informs individuals of the uses and disclosures of patient's identifiable health information that may be made by the organization, as well as the individual's rights and the organization's legal duties with respect to that information

question

privacy act of 1974

answer

a law that requires federal agencies to safeguard personally identifiable records and provides individuals wth certain privacy rights

question

protected health information

answer

a term defined n the HIPPA privacy Rule as \"individual identfiable health information that is transmitted by electronic media, maintained in electronic medium, or transmtted or maintained in any other form or medium

question

encryption

answer

a technique used to ensure that data transferred from on location on a network to another are secure from eavesdropping or interception

question

security officer or chief security officer

answer

an individual responsible for overseeing privacy policies and procedures

question

technical safeguards

answer

security measures that are based on technology rather than on adminstration or physical security, including access control, unique user identification, automatic logoff, and encryption and decryption

question

business record

answer

a record that is made and kept in the usual course of business, at or near of the event recorded

question

Uniform Photographic Copies of Business Act

answer

Act allowing record reproductions to be admitted as evidence

question

Legal Health Record

answer

Health record that is released upon request

question

Repeat Back

answer

Most effective method of insuring information given over the phone is accurate.

question

Statute of Limitations

answer

The legal, most important factor in determing the length of time that a hospital must retain medical records.

question

Integrity

answer

refers to the accuracy and completeness of information

question

E-Sign

answer

legislation giving electronic signatures increased legal standing

question

auto-authentication

answer

type of authentication contradicting basic authentication standards

question

authentication

answer

hand-written signature, rubber stamp signature and electronic signature.

question

Uniform Electronic Transactions Act

answer

Act served to make electronic transactions as enforceable as paper transactions.

question

PHR

answer

may be housed in a system that a provider owns and controls

question

countersignature

answer

signifies review and evaluation of the first provider's entry

question

Late entry

answer

Documentation to the legal record that is allowable and should be specifically noted to the time of entry to the record

question

medical staff

answer

Those with the ultimate responsiblility for the quality of care rendered in healthcare organization

question

evidence is

answer

means by which the facts are proved or disproved p.54

question

discoverability

answer

limitations on the ability of parties to discover pretrial information held by another p.55

question

metadata

answer

data about data p.57

question

legal hold

answer

issued by the court if there is concern that information may be destroyed. suspends processing or destruction of paper or electronic records p.63

question

spoliation

answer

intentional destruction,mutilation, alteration, or concealment of evidence p.63

question

admissibility

answer

evidence that is allowed to be admitted in a court of law, acquired legally and relevant p.66

question

if evidence appears relevant

answer

it must be authenticated p.67

question

physician - patient privilege

answer

encourages patients to fully disclose all relevant information p.72

question

peer review

answer

physicians reviewing physicians p.76

question

DRS Designated Record Set

answer

group of records maintained by or for a covered entity p.525

question

statutes of limitations

answer

two years from time known about p.526

question

correcting errors in documentation

answer

written in ink will be the word 'error', the time and date, and initial p.527

question

authentication

answer

doctor is the author and agrees to its contents p.528

question

hearsay

answer

did not actually hear. Medical record exempt from hearsay p.528

question

best evidence rule

answer

prevents fraud or mistakes to the contents of a document or record p.528

question

protected health care

answer

primary aim of HIPAA privacy rule p.529

question

privacy act of 1974

answer

set the stage for HIPAA. grants rights to find out about information collected, to see and copy info., to correct and amend info., and control disclosure of information p.530

question

emancipated minor

answer

take parents rights away p.538

question

power of attorney

answer

authority to act and make decisions on behalf of another party p.538

question

elements of negligence or malpractice

answer

Duty, Breach, Proximate cause, and Harm or damages p.544

question

reasonable man standard

answer

evaluate in light of own general experience p.544

question

res ipsa loquitur

answer

the thing speaks for itself p.544

question

informed consent

answer

information about anticipated treatment and its risks and alternatives p.545

question

law

answer

rules designed to protect citizens living in a civilized society p.2

question

two types of law

answer

public and private p.2

question

health information

answer

primary use is for clinical care p.2

question

him and informatics professionals

answer

individuals responsible for protecting the privacy and security of health information p.2

question

health information refers to

answer

data generated and collected as a result of delivering care to a patient p.3

question

health record comprised of

answer

information generated on a patients episode of care p.3

question

hybrid health record

answer

consists of paper and electronic records p.3

question

EHR or EMR

answer

complete electronic health record p.3

question

EHR

answer

created and managed across more than one healthcare organization p.3

question

EMR

answer

created and managed within one healthcare organization p.3

question

HIPAA

answer

Health Insurance Portability and Accountability Act of 1996 p.4

question

HITECH

answer

Health Information Technology for Economic and Clinical Health Act p.4

question

privacy

answer

to be left alone p.5

question

ASTM

answer

American Society for Testing and Materials. Now known as ASTM International (in class)

question

confidentiality

answer

sensitive data that needs to be protected from theft, disclosure, or improper use, only authorized individuals or organizations with a need to know p,5

question

privileged communication

answer

what records of communication are privileged based on providers practice p.5

question

security

answer

restricting access (in class)

question

data security

answer

effective data protection measures p.6

question

system security

answer

totality of safeguards p.6

question

information security

answer

provides integrity, confidentiality, and availability p.6

question

ownership

answer

provider who generated the record, person who created p.7

question

custodian of health records

answer

responsible for the operational functions related to the development and maintenance of records p.7

question

steward or stewardship

answer

responsible for ensuring integrity p.8

question

code of ethics

answer

morally binding (in class)

question

four ethical principles

answer

Autonomy-make ones own decision Benefience-doing good Nonmalefience-doing no harm Justice-whats right for all p.8

question

public law

answer

involves the federal, state and local government. Both civil and criminal law p.18

question

private law

answer

involves private busimesses. Only civil law p.18

question

administrative law

answer

rules and regulations created by administrative agencies p.19

question

statutes

answer

enacted by a legislative body

question

CFR Code of Federal Regulations

answer

annual editions, what was passed into law (in class)

question

stare decisis

answer

lower courts must look to higher courts

question

persuasive authority

answer

one court looks to another for guidance p.22

question

jurisdiction

answer

territory of legal control, legal authority p.22

question

three parts of government

answer

Executive branch-carries out Legislative branch-creates laws Judicial branch- judge everything p.22-24

question

HHS

answer

Health and Human Services p.22

question

separation of power

answer

provides check and balance between the three branches of government- executive, legislative and judicial p.25

question

state court system is three tier

answer

trial courts, limited jurisdiction, and general jurisdiction p.25

question

federal court system is three tier

answer

trial courts(district), appellate(circuit) and supreme court p.26

question

diversity jurisdiction

answer

enables parties from different states to engage in a lawsuit in federal court p.28

question

arbitration

answer

makes decisions (in class)

question

mediation

answer

mutual decision (in class)

question

procedural law

answer

the courts rules that guide a lawsuit p.32

question

most legal healthcare cases are

answer

civil rather than criminal p.32

question

parties in a lawsuit

answer

plaintiff and defendant p.32

question

litigation

answer

legal proceedings that accompany a lawsuit p.33

question

pro se plaintiff

answer

represents himself during litigation p.33

question

counter claim

answer

claim by a defendant against a plaintiff p.33

question

joinder

answer

defendant brings in a outsider as a codefendant p.33

question

discoverability

answer

limits on parties to discover pretrial information held by another p.34

question

deposition

answer

oral testimonies of individuals are obtained p.34

question

subpoena

answer

appointed time and place to testify under oath. issued by the clerk of court or an attorney p.34

question

interrogatories

answer

written discovery, question and answer document (in class)

question

three types of discovery

answer

deposition, interrogatories, and production of documents p.34-5

question

e-discovery

answer

key evidence contained in e-mails p.35

question

mental examination

answer

considered the fourth type of discovery p.36

question

subpoena duces tecum

answer

instructs the recipient to appear and produce documents and other records p.37

question

elements of valid subpoena

answer

name of court, plaintiff and defendants names, case docket number, date, time, place to appear with information commanded,name of issuing attorney p.38

question

motion to quash

answer

written objections to subpoenas p.38

question

preparation of documents for a subpoena duces tecum

answer

9 steps. remove material that is not requested in the subpoena p.40

question

health records are evidence in

answer

civil and criminal cases p.41

question

two types of compensatory damages

answer

Economic-medical expenses Noneconomic-pain and suffering p.46

question

punitive damages

answer

punishment for the defendant p.46

question

nominal damages

answer

awarded to recognize wrongdoing p.46

question

qui tam

answer

whistle blower (in class)

question

stare decisis

answer

let the decision stand p.519 abdelhak

question

respondeat superior

answer

let the master answer p.522 abdelhak

question

intentional tort claims include

answer

assault, battery, false imprisionment, defamation of character, invasion of privacy, and fraud p.522 abdelhak

question

assault

answer

words of threat p.522 abdelhak

question

battery

answer

touching without consent p.522 abdelhak

question

defamation of character

answer

oral-slander written- libel p.523

question

four sources of law

answer

Constitutions, Statutes, Administrative Law, Common Law

question

law is divided into two types they are

answer

public and private

question

legislative process is

answer

enacting laws in the form of statutes-they are creating laws

question

congress is made up of

answer

the senate and the house of representatives

question

express consent

answer

clearly communicated through words, whether written or spoken p.138

question

implied consent

answer

consent for medical treatment that is communicated through a persons conduct not words p.138

question

express written informed consent

answer

providers should use for risky, alternative or invasive interventions p.138 -39

question

informed consent

answer

have all the facts, basic understanding of medical procedures p.139

question

AMA suggests physicians should disclose and discuss with patients

answer

the diagnosis, nature and purpose of treatment, risks and benefits of treatment, alternatives regardless of cost, risk and benefits of alternatives, risks and benefits of not receiving treatment. These are all opportunities for patient to ask questions p.139

question

The Joint Commission requires that

answer

an executed informed consent be placed in the patient's health record prior to surgery, unless not possible because of an emergency p.139

question

IRB

answer

Institutional Review Board. They deal with research and approve it. p.140

question

in clinical trials you consent to

answer

participate and allow access to your records (in class)

question

providers who fail to properly obtain informed consent prior to performing a medical intervention run the risk of liability for

answer

battery or negligence p.141

question

Good Samaritan statute

answer

protects varies healthcare providers from liability for not obtaining a informed consent before rendering care at an accident or emergency, without compensation p.142

question

non compos mentis

answer

not of sound mind p.143

question

waiver

answer

ability of a patient to waive the right to informed consent p.143

question

the informed consent requirement for human subjects research may be waived or altered if approved by the institutional review board (IRB). To approve must have these elements:

answer

research involves no more than minimal risk to subjects, the waiver will not adversely affect the rights and welfare of the subject, research could not practicably be carried out without the waiver, subject will be provided with pertinent information after participation p.143

question

an IRB may waive the informed consent requirement when a research study involves a

answer

retrospective review of charts p.143

question

therapeutic privilege

answer

has been applied in extreme situations in which a provider believes that the risk of physical or psychological injury to the patient resulting from full disclosure outweighs the patients right to be fully informed p.144

question

GINA

answer

Genetic Information Nondiscrimination Act

question

GINA prohibits

answer

health insurance and employment discrimination based on genetic information p.144

question

advance directives

answer

means for individuals to communicate their healthcare wishes in advance should they become incapacitated. Includes living will and who has decision making power p.145 and in class

question

living wills

answer

individuals wishes to limit treatment measures when specific conditions exist and the individual cannot communicate on their own p.146

question

DNR

answer

Do Not Resuscitate, should not perform CPR. Can be revoked by patient not family p.147

question

DNI

answer

Do Not Intibate- not to go on machine (in class)

question

Patient Self Determination Act (PSDA)

answer

requires healthcare institutes that bill Medicare and Medicaid for services to provide adult patients with information about the various types of advanced directives p.148

question

Uniform Anatomical Gift Act

answer

created an opt-in system for organ donation where individuals are not considered to be organ donors unless they have specifically indicated a desire to donate p.149

question

right to die court decisions have ruled

answer

competent adults right to refuse consent to medical treatment applies even when the treatment is life saving p.151

question

when the refusal to consent is based on religious belief

answer

the First Amendment's freedom of religion clause provides additional authority for refusing treatment p.151

question

In the matter of Robert Quackenbush case

answer

the hospitals main argument was that the patient was committing suicide by refusing treatment. He was found mentally competent p.152

question

incompetent adults

answer

an individual is no longer competent due to an illness or an injury p.153

question

emancipated minors

answer

those who have been afforded legal status as an adult p.156

question

separated and divorced parents of a minor

answer

healthcare providers may first seek consent from the custodial parent. However state law should be followed regarding relative rights p.157

question

Duncan v.Scottsdale Medical Imaging

answer

plaintiff alleged that she informed defendants that she was allergic to certain medications and specifically stated that she only consented to the injection of morphine or demerol p.159

question

whether consent is written or oral

answer

it should be documented in the individuals health record p.160

question

short form

answer

orally presented must be a witness. states elements of informed consent (in class)

question

long form

answer

no witnesses needed. includes all of the informed consent requirements p.161

question

tort

answer

civil wrong for which the law will provide a remedy in the form of a lawsuit to recover damages, a wrong causing damage p.86

question

damages

answer

monetary compensation awarded by a court to an individual who has been injured p.86

question

liability

answer

legal obligation or responsibility (amount owed) p.86

question

civil law

answer

government does not get involved with, awards monetary compensation p.86

question

criminal law

answer

government prosecutes accused p.86

question

felony

answer

more serious in nature than a misdemeanor p.86

question

misdemeanor

answer

less severe crime than a felony p.86

question

jurisdiction

answer

legal authority an entity possesses to make a legal decision p.87

question

examples of intentional torts

answer

battery, assault, false imprisonment, infliction of emotional distress. Meant to do it. p.87

question

battery

answer

physical contact without permission p.87

question

assault

answer

causes apprehension, no actual contact is necessary p.88

question

false imprisonment

answer

intentional confinement of a person, use of restraints p.88

question

infliction of emotional distress

answer

key element is that it has caused additional distress p.88

question

emotional distress

answer

sleeplessness, anxiety, irritability, inability to perform activities as before p.89

question

negligence

answer

failure to act responsibly p.89

question

medical malpractice

answer

alleged wrongful act committed by a healthcare provider against a patient p.89

question

standard act of care

answer

what an individual is expected to do or not in a particular situation p.89

question

two types of negligence

answer

malpractice and criminal negligence p.90

question

criminal negligence

answer

reckless disregard for another individuals safety p.90

question

nonfeasance

answer

failure to perform an act. Didn't do it p.90

question

misfeasance

answer

improper performance of an act. Made a mistake p.90

question

malfeasance

answer

intended to cause damage. Intentional p.90

question

four elements of negligence

answer

duty, breach, approximate cause, and injury p.91

question

two types of compensatory damages

answer

non-economic and economic p.91

question

punitive damages

answer

damages that exceed compensatory damages and serve to punish the defendant p.91

question

res ipsa loquitur

answer

LIQUOR, the thing speaks for itself p.92

question

contributory negligence

answer

bars a plaintiff from recovering damages from the defendant if defendant can prove plaintiff's conduct contributed to injury suffered p.93

question

comparative negligence

answer

plaintiffs recovery to be reduced by some amount based on his or her percentage of negligence p.93

question

act of god

answer

out of human control p.95

question

charitable immunity

answer

shields hospitals and other institutions from liability for negligence p.95 and 495

question

corporate negligence

answer

going after corporation, protects the individuals p.95

question

respondeat superior

answer

let the master answer p.96

question

defamation

answer

false communication causing harm to a persons reputation p.99

question

slander is

answer

oral defamation p.99

question

libel is

answer

written defamation p.99

question

3 elements of invasion of privacy

answer

duty to not invade, breach of that duty, damages from breach p.99

question

3 elements of breach of confidentiality (fiduciary duty)

answer

duty to not disclose health information, breach of that duty, damages p.100

question

statutes of limitations

answer

limited time after problem exists p.103

question

tolled

answer

postponed, suspended, extended p.104

question

partnership

answer

two or more people agree to work together and share the risks and rewards p.120

question

sole proprietorship

answer

single owner p.120

question

corporation

answer

protects owner from personal liability for debts p.121

question

not for profit corporation

answer

can make money, not for personal use for corporation purposes p.122

question

bylaws

answer

internal rules of an organization, board of directors design p.123

question

fiduciary duty

answer

duty of loyalty and a duty of responsibility p.123

question

duty of loyalty

answer

board members put the interest of the corporation ahead of their personal interests p.123

question

duty of responsibility

answer

act with do care in exercising duties p.123

question

due diligence

answer

exercise a legally acceptable level of care p.123

question

a contract is

answer

legally enforceable oral or written agreement p.125

question

for a contract to be legal it must contain

answer

a description of the agreement, offer, acceptance, and consideration p.125

question

offer

answer

a valid promise by one party to do or not do something if the other party agrees to do or not do p.125

question

acceptance

answer

meeting of the minds on terms that are sufficiently definite and complete p.125

question

consideration

answer

what each party will receive from the other in return for performing the obligations described in the contract

question

defenses for nonperformance of a contract

answer

fraud, mistake of fact, duress, illegality, and impossibility

question

fraud

answer

doing something wrong for personal gain (in class) p.126

question

mistake of fact

answer

parties relied on information (in class) p.126

question

duress

answer

stressed into (in class) p.126

question

illegality

answer

element in contract (in class) p.126

question

impossibility

answer

acts impossible to perform (in class) p.126

question

exculpatory contracts

answer

clauses that seek to excuse a party in advance from any potential liability - \"cedar point\" p.126

question

compensatory damages

answer

attempt to return to the injured party money it would have had p.126

question

arbitration

answer

may be binding or nonbinding on the parties, in other words it makes the arbitrators decision advisory in nature p.127

question

hold harmless/indemnification clauses

answer

to either transfer or assume liability p.127

question

warranties

answer

they will fix the problem (in class)

question

learned intermediary

answer

when they learn something wrong, they have to let you know (in class)

question

physician-patient relationship

answer

letting physician know you want to enter into a contract (in class)

question

antitrust law

answer

be able to trust, to protect interest, restraint of trade (in class) not all restraints of trade are actual antitrust violations p.130

question

noncompete agreement

answer

individual agrees not to compete directly or work for a competitor for a certain period p.133

question

examples of tort reform for malpractice actions include all of the following except one:

answer

NOT affidavit of merit

question

If a patient claims negligence as the result of misuse of a laser during mole removal, the following records would probably be admissible:

answer

NOT All medical records from the physician doing the mole removal

question

the Uniform photographic copies of business and public records as evidence act (UPA):

answer

NOT allows the admissibility of reproductions into evidence in all legal cases.

question

Which of the following is incorrect? A late entry in the health record:

answer

NOT shall be documented as a late entry.

question

Which of the following types of records may be protected from discovery by privilege?

answer

NOT medical records

question

If an individual consents to treatment, but later alleges that she was not fully informed of the risks, benefits, and alternatives, what legal claim is most appropriate?

answer

NOT misfeasance

question

Physicians:

answer

NOT are only obligated to treat patients with whom a written contract has been signed.

question

what term refers to the strategic management of enterprise electronic information including standards, policies, and procedures for access, use, and control of that information?

answer

information governance

question

if parties to a contract agree to hold each other harmless for each other's actions or inactions

answer

indemnification

question

the following types of damages has been the primary target of tort reform legislation

answer

non-economic compensatory damages

question

To which of the following does GINA apply?

answer

health insurers

question

which of the following is/are required for a legal contract to be formed?

answer

all of the above

question

which type of defamation of character occurs when a false communication is made in writing about an individual?

answer

libel

question

service of a summons and complaint:

answer

both a and b

question

which of the following would constitute a violation of the federal trade commission act?

answer

offering misleading prices

question

the electronic discovery reference model (EDRM):

answer

was developed to assist in the e-discovery process

LEGAL 1-8 COMPREHENSIVE

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