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Ch5,6,7,& 8

Legal and Etical PHCC

QuestionAnswer
liability legal responsibility
defensive medicine performing medical tests and procedures to ward off litigation
documentation evidence that is written or printed
incident report an official statement of an incident
An incident report should be completed whenever anything unusual happens
memorialize when a health care provider sends a letter, by certified mail, with 30 days notice, to a patient to dissolve their doctor/patient relationship
negotiate (mediate) a meeting to agree or compromise
procedures manual a reference book explaining medical procedures
affirmative duty responding to an incident in a predetermined manner
arbitrator (arbitration) a person chosen to decide a disagreement between two parties
negotiate is AKA mediate
risk management taking steps to minimize danger, hazard, or liability
quality improvement (QI) measures taken to uphold the quality of care
QI stands for quality improvement
quality improvement (QI) is AKA quality assurance
liability insurance insurance coverage for negligent acts or omissions
vicariously liable legally responsible for someone else
respondeat superior the employer is vicariously liable for acts or omissions of their employees within the scope of their employment
statute of limitations a time limit within which one person can sue another
The statute of limitations for filing a medical malpractice lawsuit is usually 2 years
layperson one who does not have training in a specific profession
against medical advice (AMA) against medical advise
tolerance a respect for those whose opinions, practices, race, religion, or nationality differ from our own
The number one insult between medical professionals and their patients is waiting
nonverbal communication body language
aggressive hostile rather than assertive
preventive medicine medical practices designed to ward off litigation
assertiveness positive communication to prevent litigation
The most effective communication technique is silence (listening)
Apologize even when it is not your fault
Good communication techniques must be used in order to 1. Maintain customer base and encourage it to grow. . Decrease incidence of litigation.
People are less likely to sue you if they like you
Satisfied customers will tell 4 other people about your company.
Dissatisfied customers will tell 10 other people about your company.
Instead of giving advice, give information
HOH stands for hard of hearing
Do not put your hands on you hips
Do not shift blame to someone else
Do not roll your eyes
Do not finish other people's sentences
Do not talk about yourself
legal responsibility liability
performing medical tests and procedures to ward off litigation defensive medicine
evidence that is written or printed documentation
an official statement of an incident incident report
when a health care provider sends a letter, by certified mail, with 30 days notice, to a patient to dissolve their doctor/patient relationship memorialize
a reference book explaining medical procedures procedures manual
responding to an incident in a predetermined manner affirmative duty
a meeting to agree or compromise negotiate (mediate)
a person chosen to decide a disagreement between two parties arbitrator (arbitration)
taking steps to minimize danger, hazard, or liability risk management
measures taken to uphold the quality of care AKA quality assurance quality improvement (QI)
insurance coverage for negligent acts or omissions liability insurance
legally responsible for someone else vicariously liable
the employer is vicariously liable for acts or omissions of their employees within the scope of their employment respondeat superior
a time limit within which one person can sue another statute of limitations
one who does not have training in a specific profession layperson
when a patient leaves the hospital without their physician’s permission against medical advice (AMA)
a respect for those whose opinions, practices, race, religion, or nationality differ from our own tolerance
consent permission
informed consent consent obtained after the client understands the situation completely
Informed consent considerations include: 1. Educational level. 2. Primary language.
Informed consent includes: 1. Proposed treatment details. 2. Why the treatment is necessary. 3. Risks involved. 4. Available alternatives. 5. Risks of alternatives. 6. Risks if treatment is refused.
cognitive pertaining to the mental processes of comprehension, judgment, memory, and reasoning
mentally incompetent lacking reasoning faculties to understand ordinary concerns
mentally incompetent is AKA mental incapacity
Reasons for individuals to be judged mentally incompetent include: 1. Insanity. 2. Senility. 3. Being mentally challenged (MR). 4. Influenced by drugs or alcohol.
fiduciary duty an obligation of trust
delegated to appoint as one’s legal representative
agent a person legally authorized to act for another
custodian an agent delegated to care for an incapable person or property
guardian an agent delegated to care for an incapable person
A guardian is AKA a conservator
guardian ad litem an agent delegated to represent the rights of an incapable person
The order of authority to make medical decisions for a person who is mentally incapacitated: 1. Spouse. 2. Oldest adult child. 3. Parents. 4. Oldest adult sibling.
implied consent consent evident by conduct
The five Cs for correctly entering information into a medical record are: 1. Concise. 2. Complete. 3. Clear (legible). 4. Correct. 5. Chronological.
Medical information is the property of the patient
The medical record is the property of the physician or medical facility that created it
Guidelines for correcting errors in a medical record include: 1. Draw one line through the entry. 2. Write “error” and the reason for the error above or below the entry or in the margin. 3. Write the date and time the correction was made. 4. Signature and title of yourself and a witness.
minor (juvenile) under age 18
Minors cannot be treated medically without the parent’s or guardian’s consent unless: 1. It is an emergency. 2. They request treatment of a STD. 3. They request treatment for substance abuse. 4. They request contraceptives. 5. They request an abortion.
Florida law requires parental notification if a minor requests an abortion
Parental notification of an abortion can be waived by a judge if abuse is suspected
mature minor mature enough to make an informed medical decision
emancipated minor under age 18 but completely self-supporting
Florida emancipation laws state that the minor must be at least _____ years old. 16
Florida emancipation laws state that the petition must be filed by the minor's parent, guardian, or guardian ad litem
Florida emancipation laws state that the petition must show the judge that the minor is independent and able to support self and child, if parenting
Florida emancipation laws state that the minor cannot be dependent on public benefits
Florida marriage laws state that a minor cannot get married without parental consent
Florida marriage laws state that a minor under 16 cannot get married even with parental consent
Florida marriage laws state that the court can allow marriage with parental consent for a minor under 16 with a child or pregnant
A minor is not emancipated merely by becoming a parent. However, a minor parent may: 1. Maintain a child support proceeding for the benefit of the child. 2. Consent to medical care for the child. 3. Consent to medical care or services related to the pregnancy. 4. Consent to the adoption of the child.
Medical records should not be e-mailed
The Good Samaritan Act refers to rendering of emergency care without the threat of civil liability
Verify telephone numbers before faxing medical records
The Good Samaritan Act guidelines state that the care must be the same that a reasonably prudent person would render under the same or similar circumstances
The Good Samaritan Act guidelines state that the care must be without objection
The Good Samaritan Act guidelines state that the care must be free of charge
The Good Samaritan Act guidelines state that the care must be in good faith
The Good Samaritan Act guidelines state that care must be away from a medical facility
The Good Samaritan Act guidelines state that the situation must be an emergency
Do not leave medical records unattended on a fax machine or copier
Do not leave the computer unattended
Use a password for computer access and don’t make it obvious
permission consent
consent obtained after the client understands the situation completely informed consent
pertaining to the mental processes of comprehension, judgment, memory, and reasoning cognitive
lacking reasoning faculties to understand ordinary concerns mentally incompetent (mental incapacity)
an obligation of trust fiduciary duty
to appoint as one’s legal representative delegated
a person legally authorized to act for another agent
an agent delegated to care for an incapable person or property custodian
an agent delegated to care for an incapable person guardian (conservator)
an agent delegated to represent the rights of an incapable person guardian ad litem
consent evident by conduct implied consent
Examples of implied consent include: 1. Holding out arm for venipuncture. 2. Entering an emergency department.
under age 18 minor (juvenile)
A minor is AKA juvenile
mature enough to make an informed medical decision mature minor
under age 18 but completely self-supporting emancipated minor
mental incapacity lacking reasoning faculties to understand ordinary concerns
mental incapacity is AKA mentally incompetent
privacy freedom from unauthorized intrusion
Health Insurance Portability and Accountability Act (HIPAA) 1. Helps workers keep continuous health insurance coverage when they change jobs. 2. Protects confidential medical information.
Notice of Privacy Practices (NPP) a written document detailing a health care provider’s privacy practices
protected health information (PHI) information that contains patient identifiers
standard a general HIPAA requirement
transaction transmission of information between two parties for financial or administrative activities
electronic data interchange (EDI) the use of uniform electronic network protocols (formats) to transfer business information between organizations
firewall hardware, software, or both designed to prevent unauthorized access to electronic information
encryption scrambling information before sending it electronically
Is the client allowed access to their medical record? Yes, the custodian of the medical record must provide access, explanations, and copies to the client if requested.
Can the custodian charge for copies of a medical record? Yes, up to $1.00 per copy.
The only exception for the client’s ability to access their medical record is for mental health records
waives (waiver) to surrender a claim, privilege, or right
When there is doubt regarding the release of medical information, you should not disclose (even to the point of acknowledging the individual is a patient)
In order to release medical information to a third party the adult client or their agent must: 1. Provide documented identification. 2. Sign a release of medical information waiver.
According to the law, if it isn’t documented it wasn’t done
freedom from unauthorized intrusion privacy
a written document detailing a health care provider’s privacy practices Notice of Privacy Practices (NPP)
NPP stands for Notice of Privacy Practices
information that contains patient identifiers protected health information (PHI)
PHI stands for protected health information
a general HIPAA requirement standard
transmission of information between two parties for financial or administrative activities transaction
the use of uniform electronic network protocols (formats) to transfer business information between organizations electronic data interchange (EDI)
EDI stands for electronic data interchange
hardware, software, or both designed to prevent unauthorized access to electronic information firewall
scrambling information before sending it electronically encryption
to surrender a claim, privilege, or right waives (waiver)
The single most cause of injury to women is domestic violence
85% of victims of domestic violence are 9 seconds
The number of children in the US that die from abuse or neglect every day is 3
domestic violence abuse, physical or mental, that occurs within a relationship AKA
IPV stands for Intimate Partner Violence
domestic violence is AKA Intimate Partner Violence (IPV)
1 of 4 girls and 1 of 6 boys in the US will be sexually victimized before adulthood
Adult children are most frequent abusers of elders
The majority of batterers are not alcoholics but alcohol may facilitate aggressive behavior
Abuse victims may contract STDs from having sex forced upon them by nonmonogamous partners
30-50% of abused children will become abusers
Near fatal abuse and neglect each year leave 18,000 permanently disabled children
Three phases of domestic violence are 1. Slow building tension. 2. Explosion (rage) where acute battering occurs. 3. Aftermath or calmness.
In the third phase of domestic violence, the perpetrator may exhibit kind, loving behavior, vow it will never happen again, or beg forgiveness
The most frequent area of injury from domestic violence is the face
Injuries from domestic violence may go unnoticed as the practiced batterer may hit in areas that are not visible
Victims of domestic violence may hide the injuries or use excuses such as “falling” or “running into”
Typical fears of victims of domestic violence include: 1. Unknown. 2. Being alone. 3. Being considered a failure. 4. Being unable to provide for self and children.
Battering is assault and must be reported to the police
Even suspected abuse must be reported
The client must be told that suspected abuse will be reported
Women who leave batterers are at 75% greater risk of being killed by their batterer
Most people the abuser socializes with are not going to tell him he has a problem 5. Control of spouse’s daily routine. 6. Access or presence of a gun. 7. Substance abuse. 8. Sexual abuse. 9. Extreme jealousy. 10. Abuse of the children. 11. Threats or attempts of suicide.
The abuser has a strong denial system and consistently blames others for this problem
The abuser needs to be in control
The abuser has a low self-esteem
The abuser will not voluntarily seek treatment, nor be motivated to change
Effective treatment for the abuser includes: group therapy and/or incarceration
Physical indicators of child abuse include: 1. Unusual bruises and welts. 2. Unusual burns. 3. Unusual lacerations and abrasions. 4. Unusual fractures (spiral). 5. Unusual head injuries. 6. Internal injuries.
Behavioral indicators of child abuse include: 1. Overly compliant, passive, and undemanding. 2. Extremely aggressive, demanding, and rageful. 3. Role reversal. 4. Lags in development.
Passive neglect of an elder is unintentional
Active neglect of an elder is intentional
Penalties for failure to report abuse include: 1. Loss of Certificate and/or 2. Fined up to $1000.00 and/or 3. Imprisonment up to 6 months and/or 4. Civil liability for damages.
Injuries from domestic violence may go unnoticed as the practiced batterer may hit in areas that are not visible
Victims of domestic violence may hide the injuries or use excuses such as “falling” or “running into”
Typical fears of victims of domestic violence include: 1. Unknown. 2. Being alone. 3. Being considered a failure. 4. Being unable to provide for self and children.
Battering is assault and must be reported to the police
Even suspected abuse must be reported
The client must be told that suspected abuse will be reported
Women who leave batterers are at 75% greater risk of being killed by their batterer
Most people the abuser socializes with are not going to tell him he has a problem 5. Control of spouse’s daily routine. 6. Access or presence of a gun. 7. Substance abuse. 8. Sexual abuse. 9. Extreme jealousy. 10. Abuse of the children. 11. Threats or attempts of suicide.
The abuser has a strong denial system and consistently blames others for this problem
The abuser needs to be in control
The abuser has a low self-esteem
The abuser will not voluntarily seek treatment, nor be motivated to change
Effective treatment for the abuser includes: group therapy and/or incarceration
Physical indicators of child abuse include: 1. Unusual bruises and welts. 2. Unusual burns. 3. Unusual lacerations and abrasions. 4. Unusual fractures (spiral). 5. Unusual head injuries. 6. Internal injuries.
Behavioral indicators of child abuse include: 1. Overly compliant, passive, and undemanding. 2. Extremely aggressive, demanding, and rageful. 3. Role reversal. 4. Lags in development.
Passive neglect of an elder is unintentional
Active neglect of an elder is intentional
Penalties for failure to report abuse include: 1. Loss of Certificate and/or 2. Fined up to $1000.00 and/or 3. Imprisonment up to 6 months and/or 4. Civil liability for damages.
Created by: Urania