Ethics Ch. 6 and 7

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  1. A written story of a patients medical history.
    Medical record
  2. 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
  3. The medical record enables the healthcare professional to provide...
    the most appropriate patient services, especially with multiple physicians
  4. A patient who switches from Dr. to Dr.
  5. The medical record is a ______ document, its info is often a ______ source of evidence in lawsuits.
    • legal
    • primary

    what is entered in record could win or lose a legal case. 
  6. Professionals _________ in a legal case must defend what and how they record in a medical record.
  7. Every institution or office has its own practices about _______ in the medical record.
  8. What characteristics should every medical record possess?

    • F-factual
    • L-legible
    • O-objective
    • A-accurate
    • T-timely
  9. ________ 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
  10. A not-for-profit accreditation agency that reviews pt documentation.
    • The Joint Commission (TJC)
    • established in 1951
  11. "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
  12. What two things are of great significance in the medical record?
    consistency and content
  13. The info that is required for the medical record varies accross ______.
  14. What are the two common methods of charting?
    • narrative charting method
    • SOAP charting method
  15. Charting method that consists of thorough but concise documentation, including progress notes.
    Narrative Method
  16. What does SOAP stand for?
    • Subjective
    • Objective
    • Assessment
    • Plan of action
  17. SOAP subjective-
    Pt.'s chief complaints
  18. SOAP objective-
    Professional findings via examination, etc.
  19. SOAP assessment-
    conclusions based on subjective and objective information
  20. SOAP plan of action-
    treatment advised from the conclusions
  21. What is the preferred delivery method of a medical record?
    registered mail or delivery service when a signature is required
  22. Faxing and emailing are also common delivery methods of the medical record but must have
    proper documentaion of premission (some states prohibit faxing)
  23. What part of the medical record requested should be sent? what is this known as?
    • only the portion requested.
    • subpoena duces tecum
  24. "bring with you under penalty of punishment"
    subpoena duces tecum
  25. Pt.'s can decide who can access their medical info, ______ emphasizes that the patient has a right to keep their medical info private.
  26. Are there times when pt.s should not have access to their own medical records?
    • yes
    • ex. at risk groups
  27. Medical records in a computer
    • electronic medical record (EMR) or
    • electronic health records (EHR)
  28. What is a concern about using EMR's?
    their vulnerability to being hacked, potentially jeopardizing pt.s
  29. What is good about EMR's?
    More efficient collaboration by providing quicker access to written records
  30. The U.S. government mandates that by ____ that medical facilities have "meaningful use" of an EMR system.
  31. the right of the pt. to make their own decisions including about access to their medical record
  32. secure EMR's foster ______ by pt.s of their health conditions.
    • full disclosure
    • (trusting EMRs)
  33. EMR's should be available for ____ .
    • all sectors of the population, ensuring equality
    • (justice, EMR)
  34. Loyalty. This can be fostered by secure records.
  35. What are the primary sources of law in the U.S.?
    • the Constitution
    • the judicial system
    • federal and state governments
  36. The highest law in the nation, outlining rights and responsibilities of the federal government, and individuals.
    Constitutional Law
  37. Refers to the body of principles that evolve and expand from judicial decisions that arise during the trial of court cases.
    Common Law
  38. Under the guidelines of the constitution our government has three branches, what are they?
    • Executive (presidential)
    • Legislative (senate and representatives)
    • Judicial (courts)
  39. Many of the legal principles and rules applied today by courts in the US have their origins in ______.
    English common law
  40. A judicial decision that can be used as a standard in subsequent similar cases.
  41. In common law it means "the thing is decided"-refers to that which has been previously acted on or decided by the courts.
    Res Judicata
  42. Forbids the reopening of a matter that has already been finally adjudicated by competent authority.
    • Res Judicata
    • (better known as "the rule of res judicata")
  43. "let the decision stand"
    stare decisis
  44. Maintain what has been decided and do not alter that which has been established-a matter settled by the president.
    stare decisis
  45. legal principle by which judges are obligated to obey the precedents established by prior decisions
    stare decisis
  46. Stare decisis does not_______, and if need be, _______.
    • does not prevent reexamining
    • overruling prior decisions
  47. 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
  48. A specific adminstrative/regulatory law that pertains to healthcare providers is the ______.
    Controlled Substance Act
  49. In imaging, ________ law deals with licensing and regulation penalties for violation, can include suspension and revocation of license.
    Administrative/Regulatory Law
  50. 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)
    Statuatory Law
  51. In which law does the president and governors have the right to issue executive orders?
    Satuatory Law
  52. Statutory laws and executive orders must comply with _________.
    the Constitution
  53. Which law is specific to states and generally provide immunity to ordinary citizens who assist victims in an emergency
    Good Samaritan Law
  54. This law can be either civil or criminal.
    Statuatory Law
  55. A wrong against society, resulting in confinement, probation, or community service.
    Criminal Action
  56. A wrong between individuals, resulting in fines orders to perform a specific action.
    Civil Action
  57. One party asserts that the wrongful conduct of another party has caused harm.
    Tort Action
  58. Involves a claim by one party that another party has breached an agreement by failing to fulfill an obligation.
    Contract Action
  59. Criminal cases require ________, whereas civil actions require ________.
    • evidence "beyond a reasonable doubt"
    • only a "preponderance of evidence"
  60. Can an action be both criminal and civil?
    yes, criminal cases are held first
  61. Wrongs against individuals.
  62. What do intentional torts require?
    intentional interference wiht one's person, reputation, or property.
  63. Intentional torts include:
    • assult and battery
    • false imprisionment
    • defamation of character
  64. The threat of harm
  65. Actual physical harm
  66. Being held against one's will
    false imprisionment
  67. False imprisionment:
    • 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
  68. When a person's reputation is damaged by the spreading of untrue info.
    defamation of character
  69. Defamation of character can be in either ____ or _______.
    • slander-spoken
    • libel-written
  70. 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)
  71. There is at least negligence on the part of the publisher in which cause of defamation.
    • Slander
    • (harm must have resulted)
  72. False statements that concern criminal activity, a loathsome disease, business, trade, or professional misdeeds or unchasitity.
    Slander per se
  73. In Slander per se, does injury have to be proven?
    No, because it was so bad!
  74. According to Libel per se, does injury or harm have to be proven?
  75. 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
  76. What is absolute immunity to reporters involving libel per se designed to do?
    protect individuals regardless of intent
  77. How many states grand conditional immunity to defamation?
    approx, half of the states
  78. intrusion into an individuals private life without medical cause
    invasion of privacy
  79. a deceitful practice that deprives others of their rights
    • fraud
    • ex, false promises-promises not kept in healthcare are considered fraud
  80. the conversion to your own use of property you can righly access but do not own.
  81. Occurs in home health when entering a pts home
  82. often caused by intentional misconduct and may be added to any of the other charges.
    intentional infliction of emotional distress
  83. Commonly known as negligence, which can occur in any field where a duty is owed to someone.
    Unintentional torts
  84. What is the most common unintentional tort in imaging?
    • medical malpractice OR
    • professional negligence
  85. 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)
    legally liable
  86. what are Quasi-intentinal torts
    torts relating to speach
  87. a broad term that encompasses negligence, a failure to obtain informed consent, and breach of pt confidentiality.
    medical malpractice
  88. The neglect or omission of REASONABLE CARE or caution.
  89. What is the standard of Reasonable Care based on?
    the doctrine of the reasonably prudent person
  90. The failure to provide the appropriate standard of care
    professional negligence or malpractice
  91. What are the four components of unintentional torts:
    • duty
    • breach of duty(misfeasance and nonfeasance and malfeasance)
    • causation
    • damages
  92. when a professional agrees to treat a pt.
  93. failure to act as any ordinary professional within the same community in similar circumstances.
    • breach of duty
    • (has three catagories-misfeasance, nonfeasance, and malfeasance)
  94. what are the 3 catagories of breach of duty:
    • misfeasance-a mistake is made
    • nonfeasance-a failure to act
    • malfeasance- negligence with mal-intent
  95. When a mistake is made
  96. When there is a failure to act
  97. When a negligence occurs with mal-intent
  98. Requires the injury to be closely related to the negligence by the health care professional
  99. The actual injuries caused by the defendant for which compensation is due
  100. 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)
  101. "let the master answer"
    respondeat superior
  102. "the thing speaks for itself"
    res ipsa loquitur
  103. 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
  104. 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)
  105. the degree of reasonable care is determined by____.
    the applicable standard of care, by statute, or by previous judicial decesions, calls precendnts
  106. 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
  107. Attorneys, judges, and juries may take the position that if an even was not document that it _______.
    did not happen
  108. the destruction of or tampering with of legal documents, such as medical records.
  109. negligent acts that involve "reckless disregard for life or limb"
    • gross negligence
    • (is a higher degree of negligence than ordinary negligence and results in more serious penalies)
  110. an act of negligence in which the behavior of the injured part contributed to the injury.
    contributory negligence
  111. applies when the hospital as an entity is negligent
    corporate negligence
  112. What are the defences that can be adopted if blamed in a tort?
    • denial
    • assumption of risk
    • contributory negligence
    • statues of limitations
  113. claiming another cause for the damages
  114. understanding that some procedures result in commonly known injuries
    assumption of risk
  115. others are fully or partially responsible for the injury
    contributory or comparative negligance
  116. the number of years a plaintiff has to file a negligence claim (generally 3-7 years)
    statutes of limitations
  117. How long does the paintiff have to file a negligence claim?
    3-7 years
  118. 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
  119. 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.
  120. When is the borrowed servant rule used
    used by employers with temporary workers or replacement professionals for others on leave
  121. 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
  122. The surgeon is in command, usual applies in the context of the OR instead of the borrowed servant
    Captain of the ship doctrine
  123. Some employees are covered by a general liabiltiy policy and some professional associations offer liability insurance at a _______ for members
    group rate
  124. What principle provides an easy way for healthcare professionals to posture themselves to prevent a lawsuit occuring
    the PYTHON Principle
  125. 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
  126. When was the Care Bill introduced into congress and by whom?
    • 1997
    • ASRT
  127. Since 1997, _____ holds yearly RT in DC mettigs to lobby for the bill.
  128. As of ______ the care bill has not passed.
    dec. 2013
  129. What former mnuemonic for the CARE bill?
    • C- consumer
    • A-assurance of
    • R=radiologic
    • E-excelence act
  130. What is the mneumonic for the CARE Bill?
    Consistency Accuracy, Responsibity and Excellencde in Medical Imaging and Radiation Therapy Bill
  131. would require medical imaging and radiation therapist to meet federally mandated minimum education and credentialing standards for radiologic technologist
    CARE Bill
Card Set
Ethics Ch. 6 and 7
Ethics 6and7
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