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Law & Ethics For Health Professions 7Th Edition By Karen Judson – Test Bank

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  • ISBN-10 ‏ : ‎ 0073513830
  • ISBN-13 ‏ : ‎ 978-0073513836

Original price was: $50.00.Current price is: $28.00.

SKU:tb1002258

Law & Ethics For Health Professions 7Th Edition By Karen Judson – Test Bank

Chapter 07
Medical Records and Informed Consent

Multiple Choice Questions

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
A medical record is a legal document, whether on paper or electronically. While the patient has a right to a copy of the record, the record is the property of the provider(s).

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Bloom’s: Remember
CAAHEP: IX.P.7. Document accurately in the patient record
Difficulty: 1 Easy
Est Time: 0-1 minutes
Learning Outcome: 07.01
Topic: Medical records

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
Standard practice in written medical records requires that the error be acknowledged and corrected.

Accessibility: Keyboard Navigation
Bloom’s: Remember
CAAHEP: IX.P.7. Document accurately in the patient record
Difficulty: 1 Easy
Est Time: 0-1 minutes
Learning Outcome: 07.01
Topic: Medical records

3. An addendum to an electronic health record (EHR) is a:
A. note made after the patient’s 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
An addendum to the EHR is a significant change or addition to the record. While it could be something simple like a date change, it is more often completion of information. It must be signed and dated by the provider. While notes added after a visit, a surgical procedure, or lab report may be considered addendums, they are not limited to just those items.

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Bloom’s: Understand
CAAHEP: IX.P.7. Document accurately in the patient record
Difficulty: 2 Medium
Est Time: 0-1 minutes
Learning Outcome: 07.01
Topic: Medical records

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
All notes in the medical record should be pertinent to the patient’s care. His or her participation in a rally is not related to care.

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Bloom’s: Remember
CAAHEP: IX.P.7. Document accurately in the patient record
Difficulty: 1 Easy
Est Time: 0-1 minutes
Learning Outcome: 07.01
Topic: Medical records

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.
If a health care facility routinely photographs patients to document care, a special consent form should be signed stating that (1) The patient understands that photographs, videotapes, and digital or other images may be taken to document care, (2) The patient understands that ownership rights to the images will be retained by the health care facility, but that he or she will be allowed to view them or to obtain copies, (3) The images will be securely stored and kept for the time period prescribed by law or outlined in the health care facility’s policy, and (4) Images of the patient will not be released and/or used outside the health care facility without written authorization from the patient or his or her legal representative.

ABHES: 4.a. Follow documentation guidelines
Accessibility: Keyboard Navigation
Bloom’s: Understand
CAAHEP: IX.P.1. Respond to issues of confidentiality
Difficulty: 2 Medium
Est Time: 0-1 minutes
Learning Outcome: 07.01
Topic: Medical records

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
The five Cs of charting are (1) concise, (2) complete (and objective), (3) clear (and legibly written), (4) correct, and (5) chronologically ordered.

 

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