HCA Documentation and Legal Ethics 2

Question 1

Which of the following is the correct way to correct an error in a paper medical record?

Accepted Answer

Draw a single line through the error, write the correct information, and initial with date/time

Answer

Use correction fluid to cover the mistake and write the correct information

Answer

Erase the error completely and rewrite the correct entry

Answer

Tear out the page and rewrite the entire entry

Question 2

A patient's family member asks you to share the patient's diagnosis over the phone. What is the appropriate action?

Accepted Answer

Decline to share information and direct the caller to the nurse or patient's authorized representative

Answer

Share the information if the caller states they are a close relative

Answer

Verify the caller's identity and share general information only

Answer

Share the information if the patient is unconscious and unable to consent

Question 3

What does 'scope of practice' mean for a Health Care Assistant?

Accepted Answer

The range of tasks and duties an HCA is trained, competent, and legally permitted to perform

Answer

The geographic area in which the HCA is licensed to work

Answer

The number of patients an HCA can legally care for at one time

Answer

The specific hospital department where the HCA is assigned

Question 4

An HCA observes a co-worker falsifying a patient's vital signs in the medical record. What is the HCA's ethical obligation?

Accepted Answer

Report the observation to the supervising nurse or charge nurse immediately

Answer

Ignore it because it is not the HCA's responsibility

Answer

Confront the co-worker privately and threaten to report them

Answer

Document the falsification in the patient's chart personally

Question 5

Which of the following best describes 'informed consent'?

Accepted Answer

A patient agreeing to treatment after being given complete information about risks, benefits, and alternatives

Answer

A form signed by a family member on behalf of an elderly patient

Answer

The physician's decision to proceed with treatment based on clinical judgment

Answer

A verbal agreement between the patient and HCA before a procedure

Question 6

Which abbreviation is commonly considered a 'dangerous abbreviation' that should NOT be used in medical documentation according to The Joint Commission?

Accepted Answer

U (for units)

Answer

PRN

Answer

NPO

Answer

BID

Question 7

What is the primary purpose of the Health Insurance Portability and Accountability Act (HIPAA)?

Accepted Answer

To protect the privacy and security of patients' protected health information

Answer

To regulate the cost of health insurance premiums

Answer

To standardize nursing staff-to-patient ratios in hospitals

Answer

To require employers to provide health insurance to all employees