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Ch5,6,7,& 8
Legal and Etical PHCC
| Question | Answer |
|---|---|
| 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. |
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