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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following statement(s) regarding a patient's hospital medical record is(are) accurate?
- A. All the information within the chart belongs to the patient.
- B. Access to a patient's medical record is restricted to the physician, the nurse, and the patient.
- C. HIPAA guarantees the patient the right to view his or her own medical record.
- D. The patient may not take the original medical record because it is the property of the hospital.
- E. The medical record belongs to the admitting physician.
- F. The hospital must provide the patient with a written explanation of how the patient's health information will be used.
- G. The patient has the right to a copy of any or all of his or her own medical records.
Correct Answer: C,D,F,G
Rationale: HIPAA ensures patient access to records (C), originals are hospital property (D), hospitals must explain health information use (F), and patients can get copies (G). A is false as information is owned by the hospital, B is false as others may access records, and E is false as records are not owned by physicians.
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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Occurrences that should be documented on an incident report form include some of the following. Which ones are included?
- A. A patient fall
- B. A medication error
- C. A 1/4-inch scrape on a visitor's leg from brushing the leg against the edge of the wheelchair
- D. A lack of supplies needed to perform a procedure
- E. A nursing assistant bumped her head on the television mounted on the wall
- F. An unsafe staffing situation for the number and type of patients on the unit
Correct Answer: A,B,E,F
Rationale: Incident reports are needed for patient falls (A), medication errors (B), staff injuries (E), and unsafe staffing (F). Minor visitor scrapes (C) and supply issues (D) are typically not reported.
Indicate whether the following statements are True (T) or False (F). Statistics such as rates of hospital-acquired infections, mortality rates, success rates of specific procedures, and number of incidents and accidents serve as factors of a medical facility's reputation.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): These statistics are key indicators of a facility's performance and influence its reputation.
Indicate whether the following statements are True (T) or False (F). If your cursive writing is not legible, you must print your documentation on a paper chart.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Legibility is critical, so printing is required if cursive is unreadable.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. What is the military time for 1:15 a.m.?
- A. 115
- B. 1315
- C. 1115
- D. 1150
Correct Answer: A
Rationale: 1:15 a.m. is 0115 in military time (A), as it is 1:15 after midnight. 1315 (B) is 1:15 p.m., 1115 (C) is 11:15 a.m., and 1150 (D) is 11:50 a.m.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following statements is(are) true in reference to The Joint Commission?
- A. The Joint Commission audits medical records to verify facility compliance in meeting established healthcare standards.
- B. The Joint Commission sets the standards by which the quality of health care is measured nationally and internationally.
- C. The Joint Commission seeks to improve safety and quality of care that health-care organizations provide to the public.
- D. The Joint Commission is a group of commissioned individuals who collectively represent all the medical insurance companies who set the standards for medical care reimbursement.
Correct Answer: A,B,C
Rationale: The Joint Commission audits records (A), sets healthcare quality standards (B), and aims to improve safety and quality (C). D is incorrect as it does not represent insurance companies.