#1
Which of the following laws protects patient privacy and confidentiality in healthcare documentation?
Health Insurance Portability and Accountability Act (HIPAA)
ExplanationHIPAA safeguards patient privacy and confidentiality.
#2
What does PHI stand for in healthcare documentation?
Protected Health Information
ExplanationPHI refers to Protected Health Information.
#3
What does EHR stand for in healthcare documentation?
Electronic Health Record
ExplanationEHR stands for Electronic Health Record.
#4
Which of the following is an example of secondary use of healthcare data?
Research purposes
ExplanationResearch purposes exemplify secondary use of healthcare data.
#5
What is the purpose of a SOAP note in healthcare documentation?
To organize information in a structured format
ExplanationSOAP notes structure information in healthcare documentation.
#6
Which ethical principle emphasizes the healthcare provider's duty to do no harm?
Nonmaleficence
ExplanationNonmaleficence focuses on avoiding harm to patients.
#7
What is the term for the unauthorized release of confidential patient information to a third party?
Breach of confidentiality
ExplanationBreach of confidentiality is the unauthorized release of patient information.
#8
What ethical principle refers to the duty of healthcare providers to be honest and trustworthy?
Veracity
ExplanationVeracity entails honesty and trustworthiness.
#9
What is the term for a legal document that outlines a patient's healthcare wishes in the event they are unable to communicate?
Advance Directive
ExplanationAdvance Directive outlines healthcare wishes for incapacitated patients.
#10
What ethical principle refers to respecting a patient's right to make their own healthcare decisions?
Autonomy
ExplanationAutonomy respects patients' right to make healthcare decisions.
#11
Which of the following is NOT considered a best practice in healthcare documentation?
Using ambiguous language to allow for interpretation
ExplanationUsing ambiguous language is not a best practice.
#12
Which of the following is an example of a breach of patient confidentiality?
A physician discusses a patient's case with their family member without consent.
ExplanationDiscussing a patient's case without consent is a breach of confidentiality.
#13
Which of the following is NOT a key component of a valid informed consent?
Approval from the healthcare provider only
ExplanationInformed consent requires more than just approval from the provider.
#14
What is the term for the process of converting spoken words into written text?
Transcription
ExplanationTranscription converts spoken words into written text.
#15
What is the term for the process of verifying the accuracy of healthcare documentation?
Authentication
ExplanationAuthentication verifies the accuracy of healthcare documentation.