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Chapter 3 - MAD1610

The Health Care Environment: Past, Present, and Future

Advance Directive Document stating an individuals preference of treatment in the event that he/she becomes incompetent or unable to communicate with medical personnel
Bioethics Branch of ethics concerning moral issues, questions, and problems that arise in the practice of medicine and in Biomedical research
Deposition Preserve the testimony of a witness who is likely to become unavailable for trial
Ethics Standards of conduct generally accepted as a moral guide for behavior
Tort Wrongful act or injury to a person
Health Insurance Portability and Accountability Act (HIPAA) (Intended to...) (1) Limit health administration cost (2) Provide for patient information and privacy (3) Prevent against fraud and abuse
Living Will Document stating the desire of a person should he/she become incompetent because of injury or illness and death is imminent
Plaintiff One who institutes a lawsuit of action
Litigation Lawsuit
Etiquette Customary code of conduct, courtesy, and manners
Consent form One-time signed document used to disclose personally identifiable health information for treatment, payment, or routine health care operations; NOT required by law
Defendant Person being sued (either defending or denying action)
Malpractice Carelessness or negligence of a professional person
Subpoena a write that commands a witness to appear at a trial
Complaint First pleading (court document) of one who initiates action in a civil case
Authorization form Document for use and disclosure of Protected Health Information (PHI) NOT in a consent form that describes the purpose for which the health care information is to be used and disclosed
Civil Law Statue that enforces private rights and liabilities, as differentiated from criminal law
Expert Testimony Statement given concerning a scientific, technical, or professional matter by a person with authority regarding the matter
Implied consent (contract) Agreement derived because of implication or the situation, general language, or conduct of the patient
Protected Health Information (PHI) Information about the patient's past, present, or future health condition that contains personal identifying data
Grievance Committee Impartial panel established to listen to and investigate patients' complaints about medical care or excessive fees
Privileged communication Interaction between two parties in which the law recognizes a private, protected relationship. Whatever is communicated between these pairs of parties shall remain confidential, and the law cannot force disclosure of these communications
Criminal law Laws (felonies and misdemeanors) made to protect the public against the harmful acts of others.
Subpoena “Deuces Tecum" Commands the original medical record in court
Respondeat superior Let the master answer
Portability The transferbility of an insurance benefit from one source (e.g., job) to another when the worker loses or changes jobs
Health care power of attorney Document that names another individual as a decision maker for the patient when the patient is terminally ill or comatose
Covered entities Those who provide health care and/or send data electronically, such as; health care professionals, health plans, health care clearinghouses, and hospitals.
Scope of practice The range of education, training, ability, and skills a health care professional is expected to have and operate within according to the law and within the standard of care
Emancipated minors Children of any age who fall outside the jurisdiction and custody of their parents or guardians and who may make financial and medical decisions
Risk management Identifying problem practices or behaviors, then acting to control or eliminate them
Felony a crime, typically one involving violence, and usually punishable by imprisonment for more than one year
Administrative law Law that governs the activities of government agencies such as the Internal Revenue Service, Medicare, and Medicaid
Bonding- Obligation of an insurance company or bonding agency to protect an employer against financial loss caused by the acts or omissions of employees
Compliance plan- Written rules outlining practice standards that include federal and state orders
Libel- A published false statement that is damaging to a person's reputation; a written defamation
Contract law- Agreements that are legally enforceable by law between two or more parties; requires an offer, acceptance of the offer, and promise to perform
Minimum necessary standard- Limit the disclosure of PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request
Arbitration- An arrangement in which the patient waives the right to sue the physician and, instead, agrees to submit any dispute to arbitration. Arbitration agreements are legal and binding
Supremacy clause Declares the constitution, laws, and treaties of the federal government to be the supreme law of the land to which judges in every state are bound regardless of state law to the contrary
Misdemeanor An offense that is considered less serious than a felony and carries a lesser penalty, usually a fine or imprisonment for less than 1 year
Federal law A body of law at the highest or national level of a federal government.
Slander The action or crime of making a false spoken statement damaging to a person's reputation
Law The system of rules that a particular country or community recognizes as regulating the actions of its members and may enforce by the imposition of penalties
HX History
T Temperature
F Fahrenheit
A Allergies
lt Left
PND Post Nasal Drip
Rec Recommended
mg Milligrams
p.o. per oral (by mouth)
q. daily
h. hours
diag diagnosis
URI Upper Respiratory Infection
Etiol. Etiology; the cause of infection
CXR Chest X-ray
CBC Complete Blood Count
UA Urinalysis
retn Return/ Retention
Wks Weeks
Oath of Hippocrates First standards of medical conduct and ethics
medical ethics Moral principles and standards in the medical profession
Bioethics Branch of ethics concerning moral issues, questions, and problems that arise in the practice of medicine and in biomedical research
Privileged information information in a medical record
Medical Etiquette Code of conduct, courtesy, and manners customary in the medical profession
Principles of Medical Ethics modern code of ethics
HIPAA stands for Health Insurance Portability and Accountability Act
Information about patients past, present, or future health condition that contains personal identifying data is called: Protected Health Information (PHI)
The three items a VOLUNTARY signed consent form covers (1) Treatment (2) Payments (to doctor) (3) Health care opperations
What form must be obtained for use and disclosure of protected health information Authorization form (form for disclosure)
Define Compliance Plan Written document that includes office policies, procedures, and practice standards that are monitored
Common term for Litigation Lawsuit
Another phrase used for Medical Malpractice Medical Professional Liability
A physician is legally responsible for any act you preform while in his or her employ. The legal phrase used to describe this responsibility is called: (-----) and means (-----) Respondeat Superior; Let the master answer
Three circumstances in which a minor may become emancipated (1) Minor who is pregnant (2) Minor in the army (3) Minor away to school
Malfeasance wrongful treatment of the patient
Misfeasance lawful treatment done in the wrong way
Nonfeasance failure of the physician to do anything
Malpractice carelessness of negligence by a professional person
Criminal negligence Reckless disregard for the safety of another; being indifferent to an injury that could occur
Three principal defenses in a malpractice lawsuit (1) Contributory Negligence (2) Assumption of risk (3) Statue of limitations
Three alternatives to the litigation process (1) Screening panel (Grievance Committee) (2) Arbitration (Handled outside of court) (3) No fault (Malpractice insurance)
Res Ipsa Loquitor The thing speaks for itself
Respondeat Superior Let the master answer
Deuce tecum subpoena Commands the original medical record in court
Subpoena Write that commands a witness to appear at a trial
Deposition Testimony of a witness under oath and written down before a trial
Res judicata already decided by a judge
Qui facit per alium facit per se He who acts through another, acts for himself
Res gestae Things done, deed
No compos mentis Not of sound mind
4 D's Duty, Derelict, Direct cause, Damages
OSHA Occupational Safety and Health Administration
CLIA Clinical Laboratory Improvement Amendment
FDA (Food and Drug Administration) protect the health by ensuring safe pharmaceutical products
DEA (Drug Enforcement Agency) regulates the distribution of narcotics
Fraud intentional perversion of truth
Medical Directive allows patient to specify their wishes in regard to four specific dire medical situations by questionaire
Healthcare proxy someone to carry out your wishes should you be unable to
Living will how you want to live or not live
Created by: jelissa
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