CPMS Medicolegal and Compliance Questions and Answers

Question 1

The HITECH Act of 2009 significantly enhanced HIPAA regulations. Which of the following is a key provision introduced by the HITECH Act?

Accepted Answer

Mandating stricter and more detailed requirements for notifying individuals and authorities of a PHI breach.

Answer

The Health Information Technology for Economic and Clinical Health (HITECH) Act established stringent rules for breach notification. It requires covered entities to notify affected individuals, the Secretary of Health and Human Services, and in some cases the media, following a breach of unsecured Protected Health Information (PHI).

Question 2

A medical practice has a default policy of withholding all lab results from the patient portal for one week to allow providers time to review them. Under the 21st Century Cures Act, this practice could be considered a form of:

Accepted Answer

Information blocking.

Answer

The 21st Century Cures Act prohibits 'information blocking,' which is any practice likely to interfere with, prevent, or materially discourage access to electronic health information. A blanket policy that delays patient access without an individualized assessment of risk could be considered information blocking.

Question 3

To ensure compliance with CMS guidelines for scribed entries in a medical record, what is the most critical component of a scribe's attestation?

Accepted Answer

The scribe's name and the identity of the physician they are scribing for.

Answer

While institutional policies may vary, the fundamental requirement from a compliance standpoint, such as for The Joint Commission, is that the scribe's role and signature are clearly identifiable and distinguishable from the physician's. This includes clearly noting the scribe's name and the physician they served, which the physician then authenticates with their own signature.

Question 4

In the event of a medical malpractice lawsuit, which documentation practice by a scribe provides the strongest defense for the physician?

Accepted Answer

Clearly and thoroughly documenting the physician's medical decision-making process, including differential diagnoses and rationale for tests.

Answer

Thoroughly documenting the physician's thought process (Medical Decision-Making) is crucial for a legal defense. It provides a real-time record of why certain decisions were made, demonstrating that the provider considered various possibilities and acted based on sound clinical judgment, which is a cornerstone of defending against claims of negligence.

Question 5

A physician introduces their scribe to an alert and oriented adult patient, who then willingly extends their arm for a blood pressure check. The patient's action of extending their arm demonstrates which type of consent for the scribe's presence and the procedure?

Accepted Answer

Implied Consent

Answer

Implied consent is inferred from a patient's actions, conduct, or the circumstances. When the patient is informed of the scribe's presence and then cooperates with the examination without objection, they are implying their consent to the current situation.

CPMS - Certified Professional Medical Scribe Practice Test

CPMS - Certified Professional Medical Scribe Practice Test

CPMS Medicolegal and Compliance Questions and Answers