Law & Ethics for Health Professions, 8th Edition By Karen Judson – Test Bank

Law & Ethics for Health Professions, 8th Edition By Karen Judson – Test Bank

Law & Ethics for Health Professions (Judson, Revised), 8e
Chapter 7 Medical Records and Informed Consent

1) Medical records are
A) legal documents.
B) not legal documents if kept electronically.
C) always the property of the patient.
D) never the property of the patient.
E) legal documents only when a subpoena has been issued.

2) To correct an error discovered after the patient’s written copy of his or her medical records has been recorded, a medical assistant should
A) erase the mistake and type in the correction.
B) get written consent from the patient to correct the error.
C) draw a line through the mistake, make and label it as a correction, initial and date it.
D) draw a line through the error and enter the new information.
E) destroy the entry and start over.

3) An addendum to an electronic health record (EHR) is a
A) note made after the patient’s visit which is entered into the EHR.
B) surgical report added to the EHR.
C) part of the financial information for payment of services.
D) lab report added to the EHR.
E) significant change or addition to the EHR.

4) Which of the following observations should not be included in a patient’s medical record?
A) Notes regarding reaction to anesthesia.
B) Change of marital status.
C) Change in weight.
D) Notes regarding patient’s participation in a rally.
E) Notes regarding patient’s reaction to a new prescription.
5) A plastic surgeon routinely photographs patients to document care. Which of the following accurately describes information that should be included on the consent form for this type of photography?
A) The patient understands that ownership rights to the photos belong to the patient.
B) The patient understands that the photos will be kept for an undetermined time period.
C) The patient understands that he or she cannot view the photographs.
D) The patient understands that authorization must be given to release photos outside the facility.
E) The patient understands that he or she will be paid for use of the photos in marketing for the practice.

6) The five Cs are used to describe the attributes of entries into patients’ medical records. Which of the following is not one of the five Cs?
A) Clean
B) Complete
C) Clear
D) Correct
E) Chronologically ordered

7) Allison is required to have a physical before starting her job as a nurse. Her employer pays for the physical. The employer should
A) keep the physical exam records in Allison’s personnel records.
B) keep the physical exam records in a separate file from general personnel records.
C) review the physical exam records and destroy them.
D) review the physical exam records and return them to the provider.
E) review the physical exam records and return them to Allison.

8) A hospital maintains medical records on all patients treated in the hospital. Who owns the information in the hospital records?
A) The treating physician
B) The patient
C) The hospital
D) The insurance company paying the bills
E) The surgeon
9) A physician has a private practice employing a physician assistant, a nurse, and a medical assistant. The physician also has hospital privileges at a nearby facility. Who owns the medical records generated by him and the staff at the practice?
A) The public health department.
B) The physician assistant if he or she treated the patient.
C) The hospital.
D) The insurance company paying the bills.
E) The physician.

10) The doctrine of professional discretion pertains to medical record keeping. Which of the following describes this doctrine in more detail?
A) Patients should be able to obtain access to or copies of their medical records.
B) It is up to the discretion of the physician whether or not to allow all patients access to their medical records.
C) It is up to the discretion of the patient whether or not he or she may see the records.
D) It is up to the insurance company’s discretion as to whether or not a patient may see his or her records.
E) It is up to the discretion of the facility whether or not to allow patients access to their medical records.