ethics unit 2 quiz

Billing information may only be released when:

The patient gives permission and requests it

A proxy/authorized person permits it

A court order/subpoena is issued It's a matter of public concern/safety

When an error is made in documentation, what cannot be used when making corrections?

Whiteout, markers (like Sharpies), or pencil must NOT be used.

Can federal agencies require what is documented in a patient's health record?

Yes→ Federal, state, and The Joint Commission (TJC) determine what must be documented.

What is a way that an error should be corrected?

Draw a single line through the error

Include the correct entry

Date and sign it

In a legal setting, would you take originals or copies?

Only copies of health records are submitted to court. Originals stay with the facility.

If an error is discovered, who fixes it?

The person who made the error must correct it.

How can records be stored?

Hardcopy (paper or film)

CDs

Electronic systems like:

EHR (Electronic Health Record)

PACS (Picture Archiving and

Communication System)

HIS (Hospital Information System)

RIS (Radiology Information System

Are health records legal documents that are admissible in court as evidence?

Yes

Quality Management

Broad process to monitor and evaluate the quality of care. Involves all hospital staff.

Quality Assurance

A systematic program for ensuring excellence in care and image interpretation.

Quality Control

Focuses on technical aspects — ensuring equipment performance and image quality.

What type of information pertains to a patient's disease or disorder and/or filling/chart?

ICD-10-CM codes

Used to document procedures, especially for outpatient and radiology/lab services.

CPT codes

Informed Consent

signed, explained

Implied Consent

assumed based on action

Only the patient has access to his/her records — True or False?

False

establishes the standard for the maintenance and accuracy of health records

The Joint Commission (TJC)→ Along with federal and state guidelines, TJC sets documentation standards.