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Health Information Management focuses on the principles and practices involved in acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. The course covers topics such as health informatics, electronic health records (EHR), data privacy and security regulations (including HIPAA), coding systems, information governance, and the role health data plays in patient outcomes and healthcare operations. Students will explore the intersection of healthcare, information technology, and management, gaining practical skills in handling health data, maintaining confidentiality, and supporting clinical and business decision-making within healthcare environments.
Recommended Textbook
Legal and Ethical Aspects of Health Information Management 4th Edition by Dana C. McWay
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15 Chapters
625 Verified Questions
625 Flashcards
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58 Verified Questions
58 Flashcards
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Sample Questions
Q1) Res judicata is a doctrine that courts are subject to, and it means :
A) a matter [already] judged.
B) let the master answer.
C) to let the decision stand.
D) utmost good faith.
Answer: A
Q2) Civil law is also known as case law.
A)True
B)False
Answer: False
Q3) Public law _____.
A) excludes regulatory statutes,penal law,and other laws of public order
B) includes the law of contracts or torts and the law of obligations
C) involves relationships between individuals
D) is subdivided into administrative,constitutional and criminal law
Answer: D
Q4) Tort law is followed in criminal law cases.
A)True
B)False
Answer: False

Page 3
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Sample Questions
Q1) State supreme courts (except in New York State):
A) decide which cases to hear via writ of certiorari.
B) hear appeals from the intermediate appellate courts.
C) maintain guidelines concerning the type of cases.
D) try appeals from state courts involving the Constitution.
Answer: B
Q2) Which is the name of the process used by the defendant (or plaintiff)to obtain facts and information about the case from the plaintiff (or defendant)?
A) appeal
B) discovery
C) legal process
D) trial
Answer: B
Q3) The defendant's reply to the allegations of a lawsuit is called the _____.
A) Answer
B) Complaint
C) Counterclaim
D) Summons

Answer: A
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40 Flashcards
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Sample Questions
Q1) Which allows a healthcare record to be admitted into evidence?
A) business record exception
B) deposition exception
C) evidentiary exception
D) expert witness exception
Answer: A
Q2) Legal counsel,senior management/ health care providers/ governing board,HIM professional and IT professional are considered the litigation response team.
A)True
B)False
Answer: True
Q3) An approved method to challenge the validity of a subpoena duces tecum called a
A) litigation hold
B) motion to quash
C) order to deny
D) response to interrogation
Answer: B
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Sample Questions
Q1) A hospital-patient relationship is established when a patient _____.
A) asks a physician to initiate a referral for elective surgery
B) calls for information regarding available healthcare services
C) presents either voluntarily for care or in an emergency situation
D) receives and processes the hospital's bill for services provided
Q2) Describe the difference between libel and slander.
Q3) The Johnson v.Misericordia Community Hospital legal case held that:
A) A psychotherapist had a duty to warn a person that his patient was making threats to harm a third person.
B) The hospital had a duty to require that patients be examined by members of the hospital staff who were skilled in the treatment required.
C) The hospital did not apply its own credentialing rules and,therefore,did not follow its own standard of care in determining the qualifications of physicians practicing at the facility.
D) When a physician withdraws from the contractual relationship with a patient,he must provide the patient with reasonable notice to obtain a new physician or alternative treatment.
Q4) List the 3 types of damages mentioned in the textbook.
Q5) List the 4 elements that must be proven in a negligence claim.
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Sample Questions
Q1) Ethical theories refer to systematic statements or plans of principles used to deal with ethical dilemmas.
A)True
B)False
Q2) Which are among the six criteria required to assign distributive justice?
A) Ability to pay,merit,equity,social standing
B) Age,effort,merit,need
C) Need,equity,contribution,effort
D) Professional status,merit,contribution,need
Q3) Consequentialism is also known as deontology.
A)True
B)False
Q4) The Hippocratic oath expresses both _____.
A) Autonomy and nonmaleficence
B) Fidelity and autonomy
C) Justice and beneficence
D) Nonmaleficence and beneficence
Q5) What are two times that an individual looks to ethics to help?
Q6) Describe the difference between comparative and distributive justice.
7
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Sample Questions
Q1) Ethical challenges involve situations in which _____.
A) Differences in opinion have no effect
B) Just one perfect solution exists
C) Many or few provisions are included
D) There are no clear cut right answers
Q2) It is part of the supervisor's ethical role to ensure everyone has the exact desk they want within the HIM department.
A)True
B)False
Q3) One way to monitor employee conduct is to make the matter of ethics a part of the employee's performance evaluation.
A)True
B)False
Q4) Conflicts of interest are present if the health care practitioner engages in sexual relations with the patient.
A)True
B)False
Q5) List the 9 steps in ethical decision making
Q6) Describe two challenges HIM professionals deal with in a healthcare setting.
Page 8
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Sample Questions
Q1) The use of the patient's own body part for tissue transplant is called _____.
A) Allograft
B) Autograft
C) Heterograft
D) Xenograft
Q2) A child with a ruptured spleen from a bicycle accident is quickly deteriorating.His mother,a Jehovah's witness,refuses to allow a blood transfusion needed to save his life.What is the appropriate way to proceed?
A) Proceed without the mother's consent in the best interest of the child.
B) Refer to the hospital ethics committee.
C) Request the hospital administration obtain an emergency court injunction.
D) Honor the mother's wishes.
Q3) Which organization is charged with coordinating the procurement and allocation of human organs and tissues from donors to recipients?
A) UHDDS.
B) UNICEF.
C) United Way.
D) UNOS
Q4) Describe the difference between living will and durable power of attorney.
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Sample Questions
Q1) That part of the health record used for continuity of care is the _____ information.
A) Clinical
B) Demographic
C) Financial
D) Legal
Q2) Billing and reimbursement is a clinical use for a health record.
A)True
B)False
Q3) Which is an example of personal information associated with the health record?
A) Alcohol,tobacco,and work history
B) Demographic data,such as address
C) Test results and operative reports
D) Third-party payer information
Q4) A nurse writes a verbal order from a physician on the physician order sheet in the health record;the nurse is the _____ of the entry.
A) Authenticator
B) Author
C) Editor
D) Transcriber
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Sample Questions
Q1) The confidentiality of HIV information _____.
A) Does not require disclosure to the patient that re-release of such information was performed if in the best interest of the general public
B) Is protected in the same manner as any other type of protected health information,including inpatient stays and outpatient encounters
C) Means a positive test result can be disclosed without prior consent to protect the public if actions are taken to protect the patient's identity
D) Restricts identification of the patient tested and the reason for testing,but not results of the test,whether positive or negative
Q2) The right to bring a lawsuit for damages related to breach of confidentiality is protected under _____.
A) Common law
B) Constitutional law
C) Privacy law
D) Statutory law
Q3) Describe the physician- patient privilege and when is it used.
Q4) Describe the difference between a living will and durable power of attorney.
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Q1) In the modern view of ownership of health information,the health care provider owns the medium in which the patient health information is created and stored,and the patient possesses right of access.
A)True
B)False
Q2) Which is an agreement constructed to authorize a business associate's access to protected health information (PHI)under the HIPAA Privacy Rule?
A) Description of the permitted uses of released patient information.
B) Government agencies that will be impacted by release of PHI.
C) Methods for notifying the provider whenever the information is accessed.
D) Name of primary business associate who will view the patient record.
Q3) Health care information is owned by the _____.
A) facility
B) government agency
C) patient
D) treating physician
Q4) What is the role of the IRB?
Q5) List three items that must be included on a valid release of information form.
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Sample Questions
Q1) Which are subject to federal regulations regarding drug and alcohol treatment programs?
A) Facilities that provide general health care and substance abuse diagnosis/treatment.
B) General hospitals that operate a substance abuse unit that diagnoses and treats patients.
C) Mental health care organizations that provide long term care for psychiatric patients.
D) Physician offices that provide family medicine care,including treatment of anxiety.
Q2) The consent to release patient information is required when _____.
A) Audits are performed by a licensure agency
B) Information is used to screen for research
C) Litigators are seeking potential clients
D) The FDA recalls a medication or device
Q3) Mental health records can be released just like a general medical record. A)True
B)False
Q4) List the three components of a valid authorization.
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Sample Questions
Q1) Peer review committees serve to _____ as part of the quality management process..
A) Conduct audits of patient information to compare against established guidelines
B) Evaluate,maintain,and monitor risk management functions of health care services
C) Manage the organization's employees and providers credentialing process
D) Prescribe disciplinary action against employees who violate policies and procedures
Q2) State legislatures have passed laws assigning a "privileged" status to peer review deliberations and review activities,an example of which includes _____.
A) Case management records,which facilitate post-discharge care of the patient
B) Liability for libel and slander,which are implicit if documented in patient records
C) Minutes of a peer review committee,which are considered immune from discovery
D) Risk management files,which must be made accessible to patients and their families
Q3) Describe a sentinel event and give one example.
Q4) List the steps in the Utilization Review Process
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Q1) The health care provider should consider improved controls,including the establishment of written policies and procedures covering the loan and use of _____ and whether ePHI should even be maintained on these media/devices at all
A) Computer devices that are portable
B) Electronic surveillance equipment
C) Mainframe and archived computers
D) Off-site storage of paper records
Q2) E-SIGN refers to the _____.
A) Electronic Signatures in Global and National Commerce Act of 2001
B) Encryption program used by healthcare facilities that implement an EHR
C) Laws that state electronic signatures may not be used in foreign commerce
D) Programs developed to support insurance reimbursement for health care
Q3) Restricting copy functions is a risk prevention technique for an EHR.
A)True
B)False
Q4) Telemedicine is the use of electronic communications and information technologies to provide or support clinical care at a distance.
A)True
B)False
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Q1) Stark I and Stark II laws were passed because _____.
A) False misrepresentations of facts that were relied upon by another were a detriment to others and a departure from reasonable use
B) Increased federal scrutiny caused healthcare organizations to change their methods of operation,such as submitting false claims
C) Physicians were abusing the healthcare system by referring patients to services in which they (or family members)had a financial interest
D) Relators were suing on behalf of the U.S.government expressly to receive a portion of the recovered funds if the lawsuit was successful
Q2) A financial settlement that is a written agreement specifying the rules of conduct to be followed are corporate integrity agreements.
A)True
B)False
Q3) Describe the difference between upcoding and unbundling
Upcoding- submitting a bill for a higher level of reimbursement than actually rendered in order to receive a higher reimbursement rate.
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Q1) A part time worker is someone who works more than 30 hours a week.
A)True
B)False
Q2) The Americans with Disabilities Act requires employers to _____.
A) Give preference to hiring a person with a disability over a more qualified person without a disability
B) Hire a minimum of ten percent of its workforce from among qualified individuals with disabilities
C) Make accommodations for a person with disabilities no matter what the cost to the company
D) Provide qualified individuals with reasonable accommodations to performing essential job functions
Q3) Which are employed by a service firm and assigned to work at a business or an organization?
A) Independent contractors
B) Leased employees
C) Permanent employees
D) Temporary employees
Q4) Describe what Worker's Compensation is.
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