MODULE 5 STUDY GUIDE EXAM QUESTIONS WITH ALL CORRECT ANSWERS

MODULE 5 STUDY GUIDE EXAM QUESTIONS WITH ALL CORRECT ANSWERS what are the four sources of pubic and private law? - Answer-1. constitutional law = deals with the amount and types of power and authority that governments are given 2. statutes = are laws enacted by a legislative body 3. administrative laws = are developed at the direction of a legislative body when an administrative agency is given the right to develop rule and regulations that carry out the intent of statutes 4. judicial decisions = body of law created as a result of court decisions federal court system has three tiers - Answer-1. district courts - lowest tier -- jurisdiction over felonies and misdemeanors that fall under federal statutes 2. courts of appeals hear appeals of decisions made in district courts 3. the U.S. supreme court is highest courts- involving federal statutes, treaties or U.S. Supreme court petitions for writ of certiorari - Answer-are requests for review of a case by the U.S. Supreme court state court systems generally have the same three tier structure - Answer-1. trial court - lowest level tier of state courts 2. appellate courts - hears appeals of state trial court cases 3. state supreme court - highest tier. it hears appeals from the appellate courts or from trial courts when state does not have appellate courts discovery - Answer-. -- the pretrial stage in the litigation process during which both parties to a suit use various strategies to identify information about the case, the primary focus of which is to determine the strength of the opposing party's case plaintiff - Answer-.-- the group or person who initiates a civil lawsuit. defendant - Answer-.-- in civil cases, an individual or entity against whom a civil complaint has been filed; in criminal cases, an individual who has been accused of a crime deposition - Answer-.a subpoena is issued for an individual to appear at an appointed time and place and testify under oath before a reporter who transcribes the testimony.--- a method of gathering information to be used in a litigation process. subpoena ad testificandum - Answer-a subpoena that seeks a testimony-- a command to appear at a certain time and place to give testimony on a certain matter. subpoena duces tecum - Answer-for disclosure of an individual's health information must be accompanied by an authorization from that individual. -- a written document directing individuals or organizations to the furnish relevant documents and records bench trial - Answer-.-- a trial in which a judge reviews the evidence and makes a determination, without a sitting jury. voir dire - Answer-. -- the process of jury selection the physician-patient relationship is established by - Answer-either implied or expressed consent implied consent - Answer-is given by an individual when a physician is allowed to treat the individual. express consent - Answer-is granted either verbally or by signature on a consent for treatment form negligence - Answer-occurs when a healthcare provider does not do what a prudent person would normally expect the provide to do in similar circumstances three types of negligence - Answer-1. nonfeasance = is failure to act 2. malfeasance = is a wrong or improper act 3. misfeasance = is improper performance during an otherwise correct act negligence requires the following - Answer-1. the existence of a duty to meet a standard of care (degree if caution expected of an ordinary and reasonable person under given circumstances) 2. breach or deviation from that duty 3. causation, which is a relationship between the defendant's conduct and the harm that was suffered 4. injury/harm, which may be economic (medial expenses or loss of wages) and noneconomic (pain and suffering) healthcare providers can also be charged with - Answer-assault and battery, defamation, invasion of privacy, and wrongful disclosure of confidential information what are some of the things that impact the content and form of the health record? - Answer-1. state and federal statutes 2. regulation (for example, the Medicare Conditions of Participation ditation bodies such as the Joint Commission, and third- arty payers all play significant role in establishing requirements. what is the legal health record? - Answer-is the official business record created by or for a healthcare organization. the legal health record is organization-specific; therefore, its content is defined by the organization rather than by law what dictates how long health records are retained? - Answer-1. they must comply with federal and state statutes and regulations. 2. retention requirements vary by state and possibly by organization type. AHIMA recommends at a minimum record retention schedules; 1. ensure patient health information is available to meet the needs of continued patient care, legal requirements, research, education, and other legitimate uses of the organization 2. include guidelines that specify what information is kept, the time period for which it is kept, and the storage medium on which it will be maintained (paper, microfilm, optical disk, magnetic tape) 3. include clear destruction policies and procedures that include appropriate methods of destruction for each medium on which information is maintained. what is the designated record set? - Answer-a group of records maintained by or for a covered entity that may include patient medical and billing records; the enrollment, payment, claims adjudication, and cases or medical management record systems maintained by or for a health plan; or information used, in whole or in part, to make patient care - related decisions-- or for the HIPAA covered entity to make decisions about individuals what are personal health records? - Answer-personal health records are owned and managed by the individual who is the subject of the record- they are not created by or for the healthcare organization. they are NOT legal health records AHIMA retention standards - Answer-1. diagnostic images (x-ray film) = 5 years 2. disease index = 10 years 3. fetal heart monitor records = 10 years after infant reaches age of majority 4. master patient/person index = permanently 5. operative index = 10 years 6. patient health/ medical records (adults) = 10y after the most recent encounter 7. patient health/ medical records (minors) = age of majority plus statute of limitations 8. physician index = 10 years 9. register of births = permanently 10. register of death = permanently 11. register of surgical procedures = permanently