What does a medical record give the physician ability to do?
assess family medical history
compare progress or lost ground in treatment
prescrive appropriate advice
offer appropriate advice
refer to specialist
manage hospitalization, if necessary
Manage info useful for the legal system
The medical record enables the healthcare professional to provide...
the most appropriate patient services, especially with multiple physicians
A patient who switches from Dr. to Dr.
The medical record is a ______ document, its info is often a ______ source of evidence in lawsuits.
what is entered in record could win or lose a legal case.
Professionals _________ in a legal case must defend what and how they record in a medical record.
Every institution or office has its own practices about _______ in the medical record.
What characteristics should every medical record possess?
________ explains that if charting is not feasible in a timely manner, a late entry or addendum can be made but it must be clearly marked as such. This differs from adding info unethically to enhance a record for court use.
The Americal Health Information Management Association
A not-for-profit accreditation agency that reviews pt documentation.
The Joint Commission (TJC)
established in 1951
"to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value"
TJC mission statement
What two things are of great significance in the medical record?
consistency and content
The info that is required for the medical record varies accross ______.
What are the two common methods of charting?
narrative charting method
SOAP charting method
Charting method that consists of thorough but concise documentation, including progress notes.
What does SOAP stand for?
Plan of action
Pt.'s chief complaints
Professional findings via examination, etc.
conclusions based on subjective and objective information
SOAP plan of action-
treatment advised from the conclusions
What is the preferred delivery method of a medical record?
registered mail or delivery service when a signature is required
Faxing and emailing are also common delivery methods of the medical record but must have
proper documentaion of premission (some states prohibit faxing)
What part of the medical record requested should be sent? what is this known as?
only the portion requested.
subpoena duces tecum
"bring with you under penalty of punishment"
subpoena duces tecum
Pt.'s can decide who can access their medical info, ______ emphasizes that the patient has a right to keep their medical info private.
Are there times when pt.s should not have access to their own medical records?
ex. at risk groups
Medical records in a computer
electronic medical record (EMR) or
electronic health records (EHR)
What is a concern about using EMR's?
their vulnerability to being hacked, potentially jeopardizing pt.s
What is good about EMR's?
More efficient collaboration by providing quicker access to written records
The U.S. government mandates that by ____ that medical facilities have "meaningful use" of an EMR system.
the right of the pt. to make their own decisions including about access to their medical record
secure EMR's foster ______ by pt.s of their health conditions.
EMR's should be available for ____ .
all sectors of the population, ensuring equality
Loyalty. This can be fostered by secure records.
What are the primary sources of law in the U.S.?
the judicial system
federal and state governments
The highest law in the nation, outlining rights and responsibilities of the federal government, and individuals.
Refers to the body of principles that evolve and expand from judicial decisions that arise during the trial of court cases.
Under the guidelines of the constitution our government has three branches, what are they?
Legislative (senate and representatives)
Many of the legal principles and rules applied today by courts in the US have their origins in ______.
English common law
A judicial decision that can be used as a standard in subsequent similar cases.
In common law it means "the thing is decided"-refers to that which has been previously acted on or decided by the courts.
Forbids the reopening of a matter that has already been finally adjudicated by competent authority.
(better known as "the rule of res judicata")
"let the decision stand"
Maintain what has been decided and do not alter that which has been established-a matter settled by the president.
legal principle by which judges are obligated to obey the precedents established by prior decisions
Stare decisis does not_______, and if need be, _______.
does not prevent reexamining
overruling prior decisions
the federal government can create agencies with the right to implement certain laws. ex. dept. of health overseeing licentry and certification
Administrative Law or Regulatory Law
A specific adminstrative/regulatory law that pertains to healthcare providers is the ______.
Controlled Substance Act
In imaging, ________ law deals with licensing and regulation penalties for violation, can include suspension and revocation of license.
The law in which federal and state governments create their own laws, starting as bills, being approved by both legislative branches (Senate and House of Representatives) and signed by the president (federal laws) or governor (state laws)
In which law does the president and governors have the right to issue executive orders?
Statutory laws and executive orders must comply with _________.
Which law is specific to states and generally provide immunity to ordinary citizens who assist victims in an emergency
Good Samaritan Law
This law can be either civil or criminal.
A wrong against society, resulting in confinement, probation, or community service.
A wrong between individuals, resulting in fines orders to perform a specific action.
One party asserts that the wrongful conduct of another party has caused harm.
Involves a claim by one party that another party has breached an agreement by failing to fulfill an obligation.
intentional interference wiht one's person, reputation, or property.
Intentional torts include:
assult and battery
defamation of character
The threat of harm
Actual physical harm
Being held against one's will
the confined person must be aware of the confinement or must be harmed by the confinement
even if the healthcare provider does not intend harm, these allegations can be made if the pt perceives the acts to be done with the intent of harm
plaintiffs must prove that they were restrained either physically or by threat or intimidation and that they did not consent tothe restraint
hand or leg restraints are used when the pts physician order them
When a person's reputation is damaged by the spreading of untrue info.
defamation of character
Defamation of character can be in either ____ or _______.
The uttering or publishing of unprivileged false statement that hurts another's reputation.
Tort of Defamation (based on the right to maintain a good reputation)
There is at least negligence on the part of the publisher in which cause of defamation.
(harm must have resulted)
False statements that concern criminal activity, a loathsome disease, business, trade, or professional misdeeds or unchasitity.
Slander per se
In Slander per se, does injury have to be proven?
No, because it was so bad!
According to Libel per se, does injury or harm have to be proven?
Because a civil suit for slander or libel may result from reporting, what have states arranged?
They have granted immunity to reporters to encourage frank and prompt reporting
What is absolute immunity to reporters involving libel per se designed to do?
protect individuals regardless of intent
How many states grand conditional immunity to defamation?
approx, half of the states
intrusion into an individuals private life without medical cause
invasion of privacy
a deceitful practice that deprives others of their rights
ex, false promises-promises not kept in healthcare are considered fraud
the conversion to your own use of property you can righly access but do not own.
Occurs in home health when entering a pts home
often caused by intentional misconduct and may be added to any of the other charges.
intentional infliction of emotional distress
Commonly known as negligence, which can occur in any field where a duty is owed to someone.
What is the most common unintentional tort in imaging?
medical malpractice OR
When healthcare professionals are licensed they become _____ for their employment actions to uphold a standard of care (determined by what other professionals would reasonably do in a similar situation)
what are Quasi-intentinal torts
torts relating to speach
a broad term that encompasses negligence, a failure to obtain informed consent, and breach of pt confidentiality.
The neglect or omission of REASONABLE CARE or caution.
What is the standard of Reasonable Care based on?
the doctrine of the reasonably prudent person
The failure to provide the appropriate standard of care
professional negligence or malpractice
What are the four components of unintentional torts:
breach of duty(misfeasance and nonfeasance and malfeasance)
when a professional agrees to treat a pt.
failure to act as any ordinary professional within the same community in similar circumstances.
breach of duty
(has three catagories-misfeasance, nonfeasance, and malfeasance)
what are the 3 catagories of breach of duty:
misfeasance-a mistake is made
nonfeasance-a failure to act
malfeasance- negligence with mal-intent
When a mistake is made
When there is a failure to act
When a negligence occurs with mal-intent
Requires the injury to be closely related to the negligence by the health care professional
The actual injuries caused by the defendant for which compensation is due
Unintention al torts can be brought on by the employer, what is this due to? This states that employers are responsible for employees actions
the doctrine of respondeat superior
(let the master answer)
"let the master answer"
"the thing speaks for itself"
res ipsa loquitur
If the negligence is so obvious that there is no other resonable party, the burden of proof shifts to the defendant under which doctrine?
the doctrine of res ipsa loquitur
Under the Rule of Personal Responsibility, each person is.....
responsible for his or her own negligent conduct
(this law does not allow the wrongdoer to escape responsibility even though someone else may be legally liable as well)
the degree of reasonable care is determined by____.
the applicable standard of care, by statute, or by previous judicial decesions, calls precendnts
Who is the applicable standard of care generally established throught?
througt testimony of a medical expert practicing in the same field as the defendant.
expert testimony is needed to establish both the proper standard of care and a failure by the defendant to conform to that standard
Attorneys, judges, and juries may take the position that if an even was not document that it _______.
did not happen
the destruction of or tampering with of legal documents, such as medical records.
negligent acts that involve "reckless disregard for life or limb"
(is a higher degree of negligence than ordinary negligence and results in more serious penalies)
an act of negligence in which the behavior of the injured part contributed to the injury.
applies when the hospital as an entity is negligent
What are the defences that can be adopted if blamed in a tort?
assumption of risk
statues of limitations
claiming another cause for the damages
understanding that some procedures result in commonly known injuries
assumption of risk
others are fully or partially responsible for the injury
contributory or comparative negligance
the number of years a plaintiff has to file a negligence claim (generally 3-7 years)
statutes of limitations
How long does the paintiff have to file a negligence claim?
A special application of the doctrine of respondeat superior and applies when an employr lends a employee to another for a particular employment
the borrowed survant rule
what is an example of the borowed survant rule
a dr may be liable for wrongful acts committed by hospital employees under the dr.s orders. ex, a nurse can be considered an employee of the dr.
When is the borrowed servant rule used
used by employers with temporary workers or replacement professionals for others on leave
if a plaintiff sues a healthcare facility regarding actions of an employee on temporary employment , the facility may utilize the ________ to escape liablitity by blaming the actions of the temporary employee.
the borrowed servant rule
The surgeon is in command, usual applies in the context of the OR instead of the borrowed servant
Captain of the ship doctrine
Some employees are covered by a general liabiltiy policy and some professional associations offer liability insurance at a _______ for members
What principle provides an easy way for healthcare professionals to posture themselves to prevent a lawsuit occuring
the PYTHON Principle
What does the PYTHON Principle stand for:
P-Protect Y-yourself: be aware of ways to be held liable as a legal professional
T-think H-honestly: honesty is a building block in the foundations of ethis and honest dealing with pts can help prevent complications
O-observe N-naturally: keeping tract of observations; considering them all can prevent legal action
When was the Care Bill introduced into congress and by whom?
Since 1997, _____ holds yearly RT in DC mettigs to lobby for the bill.
As of ______ the care bill has not passed.
What former mnuemonic for the CARE bill?
What is the mneumonic for the CARE Bill?
Consistency Accuracy, Responsibity and Excellencde in Medical Imaging and Radiation Therapy Bill
would require medical imaging and radiation therapist to meet federally mandated minimum education and credentialing standards for radiologic technologist