WEEK 4: Chapters 25, 26                  

Chapter 25 – Health Records and Health Information Management

  1. Which of the following is not a function of a hospital health information management department?
    1. coding of diagnoses and operative procedures and diagnosis-related group assignment
    1. documenting relevant patient information in the medical record
    1. quality management and performance improvement activities
    1. appropriate release of medical information
  2. The prospective payment system is a payment system based on which of the following?
    1. the diagnosis-related group (DRG) or the ambulatory patient classification (APC)
    1. the coding system based on the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)
    1. the Current Procedural Terminology (CPT) coding system
    1. the resource-based relative value system (RBRVS)
  3. Which of the following is an example of an organization that accredits hospitals and other health care institutions in the United States?
    1. American Hospital Association
    1. American Medical Association
    1. The Joint Commission
    1. American College of Radiology
  4. The chief complaint, included in a patient’s history, is a statement made by the:
    1. physician.
    1. patient.
    1. admitting officer.
    1. admitting nurse.
  5. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation affects radiology and other hospital departments by its focus on:
    1. patient record confidentiality.
    1. facility reimbursement.
    1. quality management and performance improvement.
    1. risk management.
  6. Which of the following is not required to be included in a patient’s health record?
    1. medical history
    1. radiology reports
    1. patient’s telephone number
    1. physical examination report
  7. Criteria used in performance improvement activities must be all of the following EXCEPT:
    1. clinically valid.
    1. diagnosis or procedure oriented.
    1. generally acceptable to department staffs.
    1. written.
  8. Assessment of problems in performance improvement activities must be:
    1. ongoing.
    1. physician directed.
    1. subjective.
    1. objective.
  9. In making a correction to an entry in the paper health record, the documenter should:
    1. line out the error, authenticate, and insert correct information.
    1. erase the incorrect information, and insert correct information.
    1. leave the incorrect entry alone, and add the new correct information.
    1. remove the incorrect page from the record, and begin a new page of documentation.
  10. The organization (chart order, forms) of a hospital patient record is determined by:
    1. the accrediting body’s suggested format.
    1. Medicare regulations.
    1. the American Hospital Association–suggested format
    1. the hospital’s own preference

Chapter 26 – Medical Law

  1. If a technologist threatens a patient during the course of a procedure and has an apparent immediate ability to perform the threatened act, which of the following torts may be claimed?
    1. assault
    1. battery
    1. negligence
    1. false imprisonment
  2. The legal theory of respondeat superior requires that:
    1. the employee is responsible for the actions of the employee.
    1. each person is responsible for his or her superior.
    1. the employer is responsible for the employee’s actions.
    1. the employee is responsible for the employer’s actions.
  3. A technologist who has completed a procedure on a patient leaves the area grumbling, “I hate to do AIDS patients because I am afraid of catching the disease.” A member of the housekeeping staff hears the technologist and asks who has AIDS. The technologist responds by giving the patient’s name and room number. After this incident, housekeeping personnel refuse to clean the room. One person from housekeeping tells the story to members of the housekeeper’s church, where the patient is also a member. After learning of the patient’s condition, the church asks the patient not to return. What type of complaint might be brought against the technologist?
    1. negligence
    1. defamation
    1. assault
    1. false imprisonment
  4. The claim of false imprisonment requires the patient to show proof that the technologist restrained his or her freedom without consent. The defenses a technologist may raise include all of the following EXCEPT the:
    1. risk that the patient was going to hurt himself or herself.
    1. risk that the patient was going to hurt the technologist.
    1. life-threatening condition of the patient’s health.
    1. need for motionless images.
  5. In a case in which the legal theory of res ipsa loquitur is being raised, the evidence presented must show all the following elements EXCEPT that the:
    1. injury would not have occurred except for negligence.
    1. patient contributed to his or her injury
    1. defendant was in complete control.
    1. patient did not contribute to his or her injury in any way.
  6. A consent form has been signed by a patient who will be undergoing an excretory urogram. A witness should sign the form after the patient. Who is the best witness?
    1. a member of the patient’s family
    1. the radiographer performing the procedure
    1. a ward clerk who has no relationship with the patient or the procedure
    1. the patient’s physician
  7. Informed consent requires that the patient be given enough information to make an educated decision about his or her health care. The information the patient needs to make this decision includes all of the following EXCEPT:
    1. how the procedure will be performed.
    1. the benefits of the procedure.
    1. the alternatives to the procedure.
    1. the cost of the procedure.
  8. What complaint may be brought against a technologist if he or she touches a patient in any way without the patient’s permission?
    1. assault
    1. battery
    1. false imprisonment
    1. harassment
  9. A radiographer is performing an abdominal series on a patient from the emergency department. To complete the examination, the patient must be moved from a supine to an upright position using the remote control on the table. During this movement, the patient falls from the table and suffers a fractured hip. A complaint of negligence is brought against both the radiographer and the hospital. The elements that the patient (plaintiff) must prove include all the following EXCEPT:
    1. a breach of the duty to the patient.
    1. an injury.
    1. a direct causal relation between the breach of duty and the injury.
    1. that the radiographer acted outside of his or her scope of practice.
  10. A patient consents to a procedure in the radiology department, but after it has started, he decides that he does not want the procedure completed. The technologist should:
    1. stop immediately.
    1. complete the procedure because the patient may not revoke consent once it is given.
    1. stop the procedure as soon as it is safe to do so.
    1. none of the above should be done.

Summarize the articles assigned:

  1. Taking Action to Avoid Recurring Risk
  2. The HIPAA Paradox
  3. HIPAA Consumer

Be prepared to discuss in class.

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