Ethics Ch. 6 and 7

A written story of a patients medical history.

What does a medical record give the physician ability to do?

The medical record enables the healthcare professional to provide...

A patient who switches from Dr. to Dr.

The medical record is a ______ document, its info is often a ______ source of evidence in lawsuits.

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.

A not-for-profit accreditation agency that reviews pt documentation.

"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"

What two things are of great significance in the medical record?

The info that is required for the medical record varies accross ______.

What are the two common methods of charting?

Charting method that consists of thorough but concise documentation, including progress notes.

What does SOAP stand for?

SOAP subjective-

SOAP objective-

SOAP assessment-

SOAP plan of action-

What is the preferred delivery method of a medical record?

Faxing and emailing are also common delivery methods of the medical record but must have

What part of the medical record requested should be sent? what is this known as?

"bring with you under penalty of punishment"

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?

Medical records in a computer

What is a concern about using EMR's?

What is good about EMR's?

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 ____ .

Loyalty. This can be fostered by secure records.

What are the primary sources of law in the U.S.?

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?

Many of the legal principles and rules applied today by courts in the US have their origins in ______.

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.

"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, _______.

the federal government can create agencies with the right to implement certain laws. ex. dept. of health overseeing licentry and certification

A specific adminstrative/regulatory law that pertains to healthcare providers is the ______.

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

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.

Criminal cases require ________, whereas civil actions require ________.

Can an action be both criminal and civil?

Wrongs against individuals.

What do intentional torts require?

Intentional torts include:

The threat of harm

Actual physical harm

Being held against one's will

False imprisionment:

When a person's reputation is damaged by the spreading of untrue info.

Defamation of character can be in either ____ or _______.

The uttering or publishing of unprivileged false statement that hurts another's reputation.

There is at least negligence on the part of the publisher in which cause of defamation.

False statements that concern criminal activity, a loathsome disease, business, trade, or professional misdeeds or unchasitity.

In Slander per se, does injury have to be proven?

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?

What is absolute immunity to reporters involving libel per se designed to do?

How many states grand conditional immunity to defamation?

intrusion into an individuals private life without medical cause

a deceitful practice that deprives others of their rights

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.

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?

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

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 failure to provide the appropriate standard of care

What are the four components of unintentional torts:

when a professional agrees to treat a pt.

failure to act as any ordinary professional within the same community in similar circumstances.

what are the 3 catagories of breach of duty:

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

"let the master answer"

"the thing speaks for itself"

If the negligence is so obvious that there is no other resonable party, the burden of proof shifts to the defendant under which doctrine?

Under the Rule of Personal Responsibility, each person is.....

the degree of reasonable care is determined by____.

Who is the applicable standard of care generally established throught?

Attorneys, judges, and juries may take the position that if an even was not document that it _______.

the destruction of or tampering with of legal documents, such as medical records.

negligent acts that involve "reckless disregard for life or limb"

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?

claiming another cause for the damages

understanding that some procedures result in commonly known injuries

others are fully or partially responsible for the injury

the number of years a plaintiff has to file a negligence claim (generally 3-7 years)

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

what is an example of the borowed survant rule

When is the borrowed servant rule used

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 surgeon is in command, usual applies in the context of the OR instead of the borrowed servant

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

What does the PYTHON Principle stand for:

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?

would require medical imaging and radiation therapist to meet federally mandated minimum education and credentialing standards for radiologic technologist