Which of the following observations should not be included in a patients medical record?

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HLHS Ch 1 - 13 Quizzes
What should not be included in a patient's medical record?
What should be included in a patient medical record?
Which of the following would not be included on a patient information form?
What are the 5 components of a medical record?

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HLHS Ch 1 - 13 Quizzes

Question	Answer
Which of the following is/are not enacted by government?	Etiquette rules
A health care practitioner completes a course in law and ethics. In this field of study, Which of the following reasons should be most important to health care professionals?	To help avoid legal entanglements.
An attorney files a motion that pleads there is no basis for a trial. This is called	summary judgment.
Unlawful acts are always	unethical
The defendant in a lawsuit is the	party against whom criminal or civil charges have been filed.
What is the meaning of the term litigious?	Increase in the number of lawsuits.
Written codes of ethics for health care practitioners	evolved primarily to serve as moral guidelines for those who provide care.
A pledge for physicians that remains influential today is	Hippocratic oath.
Which of the following is a synonym for "good manners"?	Etiquette
Law may be defined as	rules of conduct.
A hospital admin makes a choice to close a wing for budget cuts even though some ppl will lose their jobs. Choice is based on results that will produce the greatest balance of good over evil, everyone considered.What type of framework is the admin using ?	Act-utilitarianism
A patient who was injured in a fall in a health care facility due to the negligence of the nurse is filing a medical malpractice lawsuit. Which ethical principle applies in this situation?	Justice
An x-ray technician witnesses a nurse diagnosing a medical problem for a patient. Which of the seven principles of health care ethics has this nurse violated?	Role Fidelity
Psychologists question how individuals develop values that guide them in ethical decision making. Which of the following reflects current thought on value development?	When people are born, they have no values in place.
A child tells a nurse that he stole money from his mother's purse because he needed to buy some candy. He also states that he knows what he did was wrong and will not do it again. What stage of moral development would this child be experiencing?	formal operational stage
A health care facility administrator considers the principle of utility when making decisions that affect the employees of the facility. Which of the following describes this principle?	It brings about positive results when generalized to a wide variety of situations.
A nurse caring for older adults in a nursing home has a paternalistic view about telling patients the truth about their conditions. Which of the following best describes the practice of paternalism?	Thinking that "I know what is best for the patient.”
A patient undergoing surgery signs an informed consent for the procedure. Which of the following principles of health care ethics does informed consent protect?	Autonomy
In Abraham Maslow's hierarchy of human needs, the need for basic life (food, shelter), a safe environment, and to belong and be loved are designated "D" needs. What does "D" stand for?	Deficiency Note: B stands for being
A person who makes a commitment to universal principles such as social justice, equal rights, and respect for the dignity of all people is in what stage of Kohlberg's developmental theory?	Postconventional morality, Stage 2
The oversight of all educational accrediting bodies in higher education is done by	U.S. Department of Education and Council on Higher Education Accreditation.
Which of the following is not sufficient grounds for revoking a medical license?	Misdiagnosis
A new long-term care facility is applying for accreditation of the facility. To which of the following organizations should the facility submit the accreditation application?	The Joint Commission
Which of these credentials is mandatory for certain health professionals to practice in their field?	Licensure
A health care profession that is certified may find the scope of practice for that profession in the __________ practice act.	medical
The largest integrated health care system in the United States is (are)	Veterans Health Administration.
Many hospitals, neighborhood health clinics, and some Blue Cross Blue Shield companies are examples of	Not-for-profit businesses
A valid out-of-state license is accepted as the basis for issuing a license in a second state without reexamination. This is called	Reciprocity
The National Practitioner Data Bank may disclose information to which of the following groups?	State licensing boards
Coinsurance is	a percentage of the fee-for-services provided that the patient pays.
Practicing medicine without a license is an example of which of the following types of laws?	criminal law
The president of the United States exercises limited legislative powers when issuing	executive orders.
Relatives of a pt. in a nursing home were prevented from seeing their family member by a staff in the nursing home. Pt. Had filed a complaint about the staff, the employee thought it right to prevent visitors. What torts might the staff be convicted of?	Trespass - wrongful injury to or interference with the property of another
According to the AHRQ, patients who are most likely to leave the hospital against physician's orders are	those who have a substance abuse problem
What brochure applies to both hospital and health care visits and encourages high quality care?	Patient Care Partnership: Understand Expectations, Rights, and Responsibilities
There are ______ branches of the federal government.	three / 3
Assault is defined as	the open threat of bodily harm.
Both parties in the physician-patient relationship have certain rights and responsibilities. Which of the following is a physician responsibility?	Exercise his or her best professional judgment in all cases.
A nurse who steals drugs from a medication cart is committing an offense under what kind of law?	Criminal law
Broad enabling statutes defining an agency's powers and procedures are known as	administrative laws.
If a patient is injured because a health care professional failed to exercise the care and expertise that under the circumstances could reasonably be expected of a professional with similar experience and training, then that professional may be liable for	negligence
When no written contract exists, who chooses an arbitrator to resolve disputes?	The two parties select an arbitrator and the two arbitrators select a third to act.
The definition of liability is	the legal responsibility of competent adults for their own acts.
A deposition may be taken in which phase of the lawsuit?	Interrogatory or Pre trial phase
Alternative dispute resolution has become increasingly popular over the years. What is the reason for this increase?	Overcrowding of court calendars
Which of the following aspects of patient care is the most vital factor in the issue of informed consent?	Patient education
A patient is properly cared for by the nurse practitioner. Which of the following describes one of the elements that the nurse practitioner has successfully met?	Duty or Duty of Care
As employers, physicians have general liability for many aspects of their business. Which of the following does not fall under the responsibility of the employers?	Employees driving to and from the workplace
A physician is a specialist in obstetrics. Which of the following is true regarding the standard of care expected of this physician?	The physician will be held to the same standard of care as other obstetricians.
Some states require mediation and/or arbitration for certain civil cases, while in other states alternative dispute resolution methods are voluntary. Under the terms of a written contract, who chooses an arbitrator?	The American Arbitration Association
A physician who owns a medical practice decides his malpractice insurance is too expensive and drops the policy. Which of the following aspects of this physician's practice will impact the physician the most?	Having hospital privileges.
Patients sue for a variety of reasons. Which of the following is not one of the top recurring reasons patients sue?	Correction of a mistake
The cost of malpractice liability insurance is based upon which of the following?	Physician specialty and dollar amount covered by the policy.
Using the process of comparative negligence, a judge determines that the patient contributed 35% to the injury and the physician contributed 65%. Which of the following is the outcome of the case?	The patient's damage award would be reduced by 35%.
A hcp who practices the "four Cs of med. malpractice prevention" finds 2 crucial benefits related to 1 of the Cs—that is, improvement in pt.s' med conditions and the decreased likelihood that they will sue. What C is most likely to provide these benefits?	Caring
Which of the following is not a form of an affirmative defense to a professional liability suit?	Denial
Which of the following insurance policies cover incidents that occurred before the beginning of the new insurance relationship but that have not yet been brought to the insured's attention as a claim?	Occurrence coverage
Methods used to manage risk are considered a part of which of the following?	Quality assurance
When the defense claims that the patient's actions caused or contributed to the injury, this is called a(n)	contributory negligence defense.
The employer physician puts a plan in place to ensure that all government regulations are enforced in the practice. This is referred to as a _________ plan.	compliance
Facebook, Twitter, and blogs are examples of	social media.
The 21 st Century Cures Act (Cures Act) is designed to	accelerate medical product development.
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?	The patient understands that authorization must be given to release photos outside the facility.
A remote consultation with physicians or other health care professionals is called	telemedicine
Which of the following observations should not be included in a patient's medical record?	Notes regarding patient's participation in a rally.
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? Correct Complete Clean Clear	Clean
The doctrine of professional discretion pertains to medical record keeping. Which of the following describes this doctrine in more detail?	It is up to the discretion of the physician whether or not to allow all patients access to their medical records.
Which of the following is not a purpose of social media? All of these are purposes of social media. Capture patient satisfaction and feedback. Emotional support for patients with similar illnesses. Awareness of causes or personal health crises.	All of these are purposes of social media.
Allison is required to have a physical before starting her job as a nurse. Her employer pays for the physical. The employer should	keep the physical exam records in a separate file from general personnel records.
An addendum to an electronic health record (EHR) is a	significant change or addition to the EHR.
While privacy is not directly expressed in the amendments to the Constitution, which of the following is one of the amendments that the U.S. Supreme Court has used to cover privacy issues?	Third
A medical assistant who is recording data in a patient's medical record maintains confidentiality at all times. Which of the following describes this practice?	Not releasing patient information to unauthorized individuals.
Which of the following statements is true about HIPAA Standard 2?	Protected Health Information (PHI) is any written, spoken or electronic form.
Which of the following is an example of a privileged communication?	A patient tells her physician that she uses illegal drugs.
As of February 2019, the single largest individual HIPAA settlement was	$16 million.
Under the Security Rule, Covered Entities must	All of these. - identify & protect agnst reasonably anticipated threats 2 the security or integrity of the information., ensure confidentiality, integrity, & availability of all PHI . create, receive, maintain, or transmit., & ensure compliance by their
How many HIPAA-defined permissions exist?	SIX
Which of the following court cases first declared that a constitutional right to privacy was implied?	Griswold v. Connecticut
What HIPAA standard requires providers and their business associates to put in place policies and procedures that ensure privacy of the health record?	Standard 2
What HIPAA standard requires providers to protect electronically transmitted and otherwise stored personal health information?	Standard 3
What of the following is not a purpose of public health functions?	Requiring physicians to take public health courses.
Who decides who gets compensation as a result of problems caused by vaccines?	U.S. Court of Federal Claims
What is the main reason for health care practitioners to report sexually transmitted infections (STIs) to the state health department?	To treat others who may be infected
Which of the following individuals with a sexually transmitted disease would be required by all states to tell a sexual partner of this disease?	A person with HIV.
Which of the following is an example of federalism?	A state retains police powers not expressively granted to the federal government.
A physician issues a medical prescription for a patient. The correct term for this practice is	prescribe
Which of the following is not required on a death certificate?	Decedent's complete medical history
The states and the federal government collect vital statistics in the United States that include births, deaths, marriages, divorces, and changes in civil status. What is the main purpose for collection of this information?	To assess population trends and needs.
Examples of public data collected by law from physicians include	births, deaths, rapes, and assaults.
A physician prescribes Oxycodone for a patient who is experiencing severe back pain. Oxycodone is an example of what schedule of drug?	Schedule II
An OSHA inspector finds that a hospital lab is operating under unsafe conditions that could endanger the lives of employees. What is the initial action that would be taken by the inspector?	Ask the employer to remedy the situation.
Employees in medical facilities often use hazardous materials in their workplace. Which of the following is a guideline for safely handling these materials?	The employer must provide a Safety Data Sheet for each hazardous chemical.
Which of the following is an OSHA guideline for disposal of medical waste material?	Dispose of chemicals in a glass or metal container.
Which of the following acts mandated that employers maintain a sharps injury log and involved nonmanagerial employees in selecting safer medical devices?	Occupational Exposure to Bloodborne Pathogens Standard
Which of the following federal laws makes it illegal to discriminate in hiring or firing because of union membership or organizational activities?	Wagner Act of 1935
An employee who is laid off from his job files for unemployment insurance. Which of the following accurately describes the management of unemployment funds available to this worker?	In all but a few states, the total cost is covered by the employer.
Sarah is starting a new job as a medical assistant at a local clinic. Under OSHA regulations, what must her employer offer her as part of her employment?	No-cost hepatitis B vaccinations
In 2012, OSHA published the first major revision to the Hazard Communication Standard. What was the main purpose of the revision?	Transform the right of employees to know about workplace hazards to the "right to understand" workplace hazards
Which of the following information should not be included on an employee's W-2 form?	Amounts deducted for life insurance.
In the revision to the Hazard Communication Standard, OSHA created a new name for Material Safety Data Sheets. What is the new acronym?	SDS
The children in a family all have blue eyes. The biological parents also have blue eyes. The science that explains these similarities is called	genetics
In 2008, what federal law was passed that prohibits discrimination in employment based on genetic information?	GINA
Infertility is considered to be the failure to conceive in how many months or longer?	12
What court case allows for patenting of live human-made organisms?	Diamond v. Chakrabarty - Case over genetically engineered micro-organisms that breaks down crude oil
A 17-year-old female lives with her parents and meets the requirements to give informed consent to have a small basal cell carcinoma removed. Which of the following would this teenager be considered?	Mature minor
A young infertile couple asks their physician about adopting a baby. Which of the following statements is true regarding the process of adoption?	Any adult who shows the desire to be a fit parent may adopt a child.
Which of the following types of adoption generally involves placing children who have been orphaned or whose parents have lost or relinquished parental rights through abuse, abandonment, or the inability to support them?	Agency adoption
Scientists are able to manipulate DNA within the cells of plants, animals, and other organisms to ensure that certain advantageous traits will appear and be passed on, or that certain harmful traits are eliminated. What is the term for this process?	Genetic engineering
A fertility specialist brings an infertile couple's eggs and sperm together in a test tube and when fertilization occurs, he transplants the resulting embryo back into the female uterus. What is the term for this type of fertilization?	In vitro fertilization
A new mother leaves her infant daughter in a safe place at a nurse's station in a hospital. This mother is protected from legal prosecution or with reduced legal prosecution by what legislation?	Safe haven law
Which of the following is not a goal of palliative care?	Using current research studies to find a cure for a terminal illness.
What aspect of death and dying did the late Elisabeth Kübler-Ross, MD, describe?	The coping methods of persons who are grieving
Which state law was the first state law passed to permit physician-assisted suicide in certain circumstances?	Oregon's Death with Dignity Act
A medical board subspecialty in hospice and palliative care requires a physician to be board certified in a specialty such as internal medicine, surgery, or family medicine. What is(are) the other requirement?	Completing a one-year fellowship in hospice and palliative care.
For patients to be eligible for hospice care, physicians usually must certify that they are not expected to live beyond how many months?	6 months
What is true about living wills?	A living will may identify which heroic measures may be used, A living will may detail specific treatments that may be stopped, and Each state may have different regulations regarding living wills. All of these are correct.
What was the purpose of the creation of the Uniform Anatomical Gift Act?	To allow individuals to donate their bodies to science after death.
Technically, it can be said that death results from a lack of what?	oxygen
What organ can NOT be transplanted?	brain
A patient asks his physician "Can you help me die in peace?" The physician agrees to withhold medical treatment for this patient. This is an example of what type of euthanasia?	Passive
The AHRQ Report for 2017 indicated that	the United States spend more on health care and its citizens were less healthy than those in other nations.
For fair access to health care to exist, there must be which of the following?	Adequate services for all, ability of population to utilize the system, and ability of individuals to receive ongoing care must all be in place
Under the 2010 PPACA, insurance co's do the following except phase out annual & lifetime limits to coverage. remove insur co blocks to emrgenc service., no longr limit / deny cover to pts under 19 with preexistings, cover child up to age 30 on their p	cover children up to age 30 on their parents' health insurance policy.
Employers hope to contract with health care providers who can deliver quality services at a reasonable cost because they provide which of the following to their employees?	Health care benefits
Which of the following may be traded on the nation's stock market? Pharmaceutical companies State children's health insurance program Volunteer organizations Professional organizations	Pharmaceutical companies
What is the term for those individuals who have a vested interest in the health care industry?	Stakeholders
What must a nonprofit health insurance organization do if at the end of the budget year, they have made a profit?	Put the profit back into services for those covered under their insurance.
Which of the following stakeholders are considered to be at the head of the list?	The public
Infant mortality is one major measure of a country's health system. The United States infant mortality rate is	ranked near the bottom of comparable countries.
According to the 2017 AHRQ report on quality and disparities, patient safety improved to include	two-thirds of patient safety measures were improving overall.

What should not be included in a patient's medical record?

Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney, Unprofessional or personal comments about the patient, or.

What should be included in a patient medical record?

Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication.

Which of the following would not be included on a patient information form?

Patient information forms usually do not contain medical histories; these are most often completed on separate forms.)

What are the 5 components of a medical record?

Key components of a medical record:.

Patient demographic data such as age, sex, nationality, etc..

Social screenings such as their profession, etc..

Information about their genetics..

Medical history and diagnosis received so far..

List of medicines..

List of vaccinations the patient has received..

Lab test results..

Which of the following observations should not be included in a patients medical record?

HLHS Ch 1 - 13 Quizzes

What should not be included in a patient's medical record?

What should be included in a patient medical record?

Which of the following would not be included on a patient information form?

What are the 5 components of a medical record?

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