Healthcare Law

Health Law Chapter 7 Worksheet

Q1: Briefly summarize the American Health Information Management Associations definition for a legal health record.
A: Generated at or for a healthcare organization as its business record and is the record that would be released upon request

Q2: What is a designated record set?
A: a group of records consisting of one or more of the following types of information about individuals, medical and billing records, information about health plan enrollment., payment, claims, adjudication, and case or medical management record systems, and other information used to make health care decisions.

Q3: Who establishes the standards for record maintenance, content, and documentation requirements?
A: AHIMA

Q4: Who has the ultimate legal responsibility for the quality of care rendered in a healthcare organization?
A: The Joint Commission

Q5: List 2 – 3 persons who may be permitted to document and authenticate entries in a health record.
A: Physician, Nurse, HIM Professional

Q6: Gaps and omissions in a health record can leave an organization susceptible to liability. Is this a true statement?
A: True

Q7: Name the 2 types of physician orders.
A: Verbal and Written

Q8: In reference to physician orders, what is meant by read-back?
A: Authenticate the order by reading it back for accuracy

Q9: Why is it important to document facts when dealing with a hostile or irritated patient?
A: In the case of liability issues

Q10: What happens when staff disagreements in patient care is documented in the patient’s record?
A: They can lead to liability issues unless it is properly documented the courts will uphold the intervention.

Q11: Missing or incomplete information in a health record may infer provider negligence. Is this a true statement?
A: True

Q12: What does integrity mean?
A: The state of being whole or unimpaired

Q13: What is the difference between authenticity and authentication?
A: authenticity is the...