Lesson 8: Medical Records & Principles of Ethics

What is required for a patient to authorize a medical record release?

• verbal consent

• email confirmation

• written authorization

• physician approval

Which charging format tracks care chronologically by problem?

• SOAP

• POMR

• SOR

• CHART

When must final notes be completed by a physician after hospital discharge?

• up to 10 days after

• up to 15 days after

• up to 30 days after

Which situation permits disclosure without consent under law?

• doctor feels it is unhelpful

• emergency care

• social media post

• patient request

Why can a physician deny a patient access to their own record?

• patient is under 18

• against policy

• due to medical/emotional risk

• record is incomplete

How long must records be stored after last entry?

• 5 years

• 7 years

• 10 years

• until patient dies

When does the retention clock start for pediatric records?

• at birth

• at treatment date

• at age of maturity + statue of limitations

• after graduation

What does the Privacy Act of 1974 apply to?

• private clinics

• all hospitals

• federal agencies

• all physicians

What protects drug and alcohol abuse patient confidentiality?

• HIPAA

• Public Health Services Act

• CDC guidelines

• Hospital bylaws

What is a subpoena duces tecum?

• consent form

• order for emergency care

• court order to bring records

• research approval