A method of documenting nurses' progress notes by recording only abnormal or unusual
findings or deviations from the prescribed plan of care is called:
→ Charting by exception
The discharge summary must be completed within _________ after discharge for most
patients but within ________ for ...
What is the implication regarding the confidentiality of incident reports in a legal proceeding
when a staff member documents in the health record that an incident report was completed
about a specific incident
→ The data, documents, reports and information that comprise the formal business records
of any healthcare entity that are to be utilized during legal proceedings
Anywhere Hospital's coding staff will be working remotely. The entity wants to ensure that
they are complying with the HIPAA security rule. What type of network uses a private tunnel
through the internet as a transport medium that will allow the transmission of ePHI to occur
between the coder and the facility securely?
→ Virtual private network
An individual designated as an inpatient coder may have access to an electronic medical
record in order to code the record. Under what access security mechanism is the3 coder
allowed access to the system?
→ Role-based
The privacy rule generally requires documentation related to its requirements to be retained:
→ 6 Years
Which legal doctrine was established by the Darling v. Charleston Community Hospital case of
1965?
→ Corporate Negligence
Linda Wallace is being admitted to the hospital. She is presented with a "Notice of Privacy
Practices" In the Notice, it is explained to her that PHI will be used and disclosed for
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