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Medical Records

Question 10 • *GV 2018 - P.E. Health Science - PE201

Decide whether the healthcare professional in each scenario has done the correct or incorrect thing with regard to properly obtaining, handling, or distributing a patient’s personal health information. You are meeting a new patient for the first time. You ask whether she prefers to be called Barbara, Mrs. Sanchez, or some other name. She says she actually prefers her nickname, Bunny, which is what everyone calls her. You then call her “Bunny” for the rest of her stay. correctincorrectA patient with persistent diarrhea is found to have an infection that is unusual in the United States. It turns out that he recently returned from a trip to Central America, where he suspects he ate raw produce that was washed in contaminated water. The doctor jots all of this information down in the patient’s medical record. The information is considered protected health information. correctincorrectSix months later, the doctor described in the previous scenario reports information on the patient’s symptoms, diagnosis, travel to Central America, and treatment outcome to the federal Centers for Disease Control and Prevention, which is studying outbreaks of this infection. correctincorrect

Answer
A
correct
B
incorrect

Explanation

Calling the patient “Bunny” is correct because you asked her preference and used the name she chose. The infection, travel history, and related details in her medical record are protected health information because they relate to her health and are linked to her as a patient. Reporting relevant information to the CDC for outbreak monitoring is also permitted as a public health disclosure, so the doctor does not need the patient’s authorization for that report.

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