HSA 5425 Florida National University Medical Health Essay

Chapter 12Patient Consent
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LEARNING OBJECTIVES – I
▪ Explain the concept of informed consent.
▪ Describe role of the patient, physician, nurse, & hospital in informed
consent.
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▪ Discuss difference between verbal, written, & implied consent.
LEARNING OBJECTIVES – II
▪ Discuss under what circumstances a patient might refuse treatment.
▪ Explain the available defenses for defendants as it relates to informed
consent.
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▪ Explain how consent differs between competent patients, minors,
guardians, and incompetent patients.
Consent
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▪ Voluntary agreement by a person who possesses sufficient mental
capacity to make an intelligent choice to allow something proposed by
another to be performed on himself or herself.
Informed Consent
▪ Patient has absolute right to know about & select from available
treatment options.
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▪ Legal doctrine where a patient has right to know potential risks, benefits,
& alternatives of a proposed procedure.
Forms of Consent
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▪ Express consent
▪ Verbal
▪ Written
▪ Implied Consent
▪ Generally be presumed when immediate action is required to
prevent death or permanent impairment of a patient’s health
▪ e.g., treatment of accident victim
Forms of Consent – II
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▪ Statutory Consent
▪ Many states have adopted legislation allowing for emergency
care.
▪ Judicial Consent
▪ Allowed when there is concern as to the absence or legality of
consent.
Physicians
Informed Consent
▪ Physicians expected disclose risks, benefits, & alternatives of
recommended procedures.
▪ Disclosure: what a reasonable person would consider material to a
decision of whether to or not to undergo treatment.
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▪ Informed consent is predicated on duty of the physician to disclose
sufficient info to enable patient to evaluate proposed medical or surgical
procedures before submitting to them.
Nurses
Informed Consent
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▪ Nurses most cases have no duty to
▪ advise a patient as to a surgical procedure to be employed
▪ may confirm physician has explained the procedure
▪ witness patient’s signature on consent form
Hospitals
Informed Consent
▪ Some cases in which hospitals have a duty
▪ CT Scans
▪ MRI Imaging
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▪ Not generally responsible for informing patients as to the risks, benefits
and alternatives.
Patients
Informed Consent
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▪ Patient’s ability to:
▪ understand risks, benefits, & alternatives
▪ evaluate info provided by the physician
▪ express his or her treatment preferences
▪ voluntarily make decisions regarding his or her treatment plan
CASE: Course of Treatment
Patient’s Decision
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Elderly woman living alone fell & fractured her hip. An orthopedic
surgeon reviewed the patient’s condition & decided that rather than
utilizing a pinning procedure for her hip, it would be better to adopt a
conservative course of treatment, bed rest.
CASE: Course of Treatment
Patient’s Decision – II
▪ Expert testimony at trial indicated that bed rest was an inappropriate
treatment.
▪ Was the patient successful for not being informed as to alternatives
courses of treatment?
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▪ Prior to her injury, plaintiff maintained an independent style of living.
CASE: Court’s Decision
−Matthies v. Mastromonaco
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▪ Court held that it is necessary to advise a patient when considering
alternative courses of treatment. The physician should have explained
medically reasonable invasive & noninvasive alternatives, including risks
& likely outcomes of those alternatives, even when the chosen course is
noninvasive.
CASE: Lack of Consent
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Patient had multiple medical diagnoses. Her physician, Dr. Sottiurai,
ordered bilateral arteriograms to determine cause of the patient’s
impaired circulation. De La Ronde Hospital could not accommodate
Sottiurai’s request & patient was transferred to Dr. Lang, a radiologist at
St. Jude Hospital.
CASE: Lack of Consent – II
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Lang performed a femoral arteriogram, not the bilateral brachial
arteriogram ordered by Sottiurai. The patient was prepared for transfer
back to De La Ronde Hospital. Shortly after the ambulance departed,
patient suffered a seizure in the ambulance & was returned to St. Jude.
Riser’s condition deteriorated & died 11 days later.
▪ What did the trial court determine?
CAST: Trial Court Decision
▪ On appeal, what did the appeals court determine?
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▪ The district court ruled for the plaintiffs, awarding damages in the
amount of $50,000 for Riser’s pain and suffering and $100,000 to
each child. Lang appealed.
CASE: Appeals Court’s Decision
−Riser v. American Medican Intern, Inc.
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▪ The Court of Appeal held that Lang breached the standard of care by
subjecting the patient to a procedure that would have no practical benefit
to the patient, that Lang failed to obtain informed consent from the
patient.
Information to be Disclosed
▪ Needs of each patient can vary depending on age, maturity, & mental
status.
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▪ Physician should provide as much information about treatment options
as necessary based on a patient’s personal understanding of physician’s
explanation of risks of treatment & probable consequences of treatment.
Information to be Disclosed – II
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▪ Individual responsible for obtaining consent must weigh importance of
giving full disclosure to the patient against likelihood such disclosure will
adversely affect the patient’s decision.
Information to be Disclosed – III
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▪ Courts generally utilize an “objective” or “subjective” test
▪ to determine if a patient would have refused treatment if the physician
had provided adequate information
▪ as to the risks, benefits, & alternatives of the procedure.
Subjective test
▪ Relies on credibility of the patient’s testimony
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▪ Patients must testify & prove they would not have consented to the
procedure(s) had they been advised of the risks.
Objective Test
▪ Take into account characteristics of the plaintiff
▪ Must show that a “reasonable person” would not have undergone a
procedure if properly informed.
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▪ idiosyncrasies, fears, age, medical condition, and religious belief
Assessing Decision-Making Capacity
2. Patient evaluates the information provided by the physician.
3. Patient expresses his/her treatment preferences
4. Patient Voluntarily makes decisions regarding his or her treatment plan
without undue influence (e.g., family, medical personnel)
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1. Patient understands risks, benefits, & alternatives of a proposed test or
procedure
Adequacy of Consent
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▪ Patient:
▪ understand risks, benefits, & alternatives
▪ evaluates the information provided
▪ expresses treatment preferences
▪ voluntarily makes decisions regarding treatment plan
Verbal Consent
▪ As binding as written consent.
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▪ More difficult to corroborate.
Written Consent Describes
▪ Nature of the patient’s illness
▪ Risks & probable consequences of the procedure
▪ Probability that the proposed procedure will be successful
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▪ Procedure consented to
Written Consent Describes – II
▪ Indication the patient understands nature of proposed treatment
▪ Signatures dated & signed
▪ patient
▪ physician
▪ witnesses
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▪ Alternative methods of treatment
▪ Associated risks & benefits of each
Special Forms of Consent
▪ Admission Consent
▪ Consent for Specific Procedures
▪ Implied Consent
▪ Statutory Consent
▪ Judicial Consent
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▪ Consent for Routine Procedures
Statutory Consent
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▪ Consent generally assumed
▪ Ambulance Care
▪ Good Samaritan Statutes
▪ Emergency Departments
▪ When patient clinically unable to give consent
Judicial Consent
▪ May be periodically necessary
▪ 2nd opinions by consulting physicians helpful
▪ On-call legal advice should be sought
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▪ When alternatives exhausted
Who May Consent
▪ Competent patients
▪ Parental Consent
▪ Emancipated Minor
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▪ Guardianship
INCOMPETENT PATIENTS
▪ Ability to consent to treatment is a question of fact.
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▪ When a physician doubts a patient’s capacity to consent, even though
the patient has not been judged legally incompetent, the consent of the
nearest relative should be obtained.
LIMITED POWER OF ATTORNEY
▪ Such consent for treatment provides limited protection in the care of a
particular child.
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▪ Parental authority to have, for example, school officials & camp
counselors to act on a parents’ or legal guardian’s behalf when seeking
emergency care.
Refusal of Treatment
▪ Refusal of Treatment: Religious Beliefs
▪ Blood or blood products
▪ Impatience
▪ Text Case: Good People Bad Decisions
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▪ For any or no reason
▪ Mere whim
Discharge Against Medical Advice
▪ Refusal to consent to treatment.
▪ Release form should be executed.
▪ Discharge/Leaving Against Medical Advice
▪ Note if patient refuses to sign release.
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▪ Completed release provides documented evidence of a patient’s refusal
to consent to a recommended treatment.
When in Doubt
▪ Error on the Side of Life
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Informed Consent Defenses
▪ Risk not disclosed is commonly known.
▪ Consent not reasonably possible.
▪ Physician disclosed what he considerable reasonable
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▪ Patent did not want to know about the risks.
Ethics
Informed Consent
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▪ Individual Autonomy
▪ Informed consent protects the basic right of the patient to make the
ultimate informed decision regarding the course of treatment to which
he or she knowledgeably consents.
▪ Consent forms should be used as a supplement to the oral disclosure
of risks, benefits, and alternatives to the proposed procedure that a
physician normally gives.
REVIEW QUESTIONS – I
2. Describe what information a patient should be provided prior to
undergoing a risky procedure in order for consent to be informed.
3. Why is it important to obtain consent from a patient prior to proceeding
with a risky procedure?
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1. Who should be responsible for reviewing with the patient the risks,
benefits, and alternatives of a proposed diagnostic test or treatment?
REVIEW QUESTIONS – II
5. Can a parent refuse to consent to a lifesaving procedure
for his or her child? Discuss your answer.
6. Discuss how much information is sufficient in order for
informed consent to be effective (e.g., consider your
answer here from both the objective and subjective forms
of consent).
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4. Can a patient consent to a procedure and then withdraw
it?
REVIEW QUESTIONS – III
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7. Discuss the implications of the following statement: “Patients are
generally persons unlearned in the medical sciences and, therefore,
except in rare instances, the knowledge of patient and physician is not in
parity.”
Chapter 10
Hospital
Departments &
Allied
Professionals
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LEARNING OBJECTIVES
▪ Discuss the purpose of certification, licensure, & reasons for revocation
of licenses.
▪ Discuss the purpose of the Emergency Medical Treatment 7 Active Labor
Act.
▪ Explain the importance of a multidisciplinary approach to patient care.
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▪ Describe the wide variety of negligent errors by various health care
professionals.
PARAMEDICS
▪ Emergency Medical Technician
▪ Advanced Emergency Medical Technician
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▪ Emergency Medical Technician
PARAMEDICS – II
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▪ Paramedic
▪ Wrong Drug Dosage Administered
▪ Protected by Good Samaritan Statute
▪ Inability to Diagnose Extent of Injury
▪ Patient Refuses Transport
▪ License Denied
▪ Patient Refuses Transport and Expires
Emergency Department
Objectives
▪ All Patients are Treated
▪ Treatment must begin as rapidly as possible to
▪ Maintain Function
▪ Prevent, Minimize Scarring & Deformity
▪ Care & Treatment Regardless of Ability to Pay
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▪ Patients are Assessed
CASE: No Duty to Patient
Who Left ED Untreated
−Griffith v. University Hospitals of Cleveland
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▪ In a wrongful death medical malpractice action alleging negligence, the
trial court properly granted summary judgment because under Ohio law,
an emergency room nurse had no duty to interfere with an individual who
left the ED without telling anyone and who refused treatment.
CASE: Failure to Admit
−Roy v. Gupta
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▪ Physician was found negligent in failing to hospitalize the patient or
failing to inform her of the serious nature of her illness. The trial court
found that had the patient been hospitalized on her first visit, her
chances of survival would have been increased.
Documentation Sparse & Contradictory
−Fenney v. New England Medical Ctr.
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▪ ED physician failed to evaluate the patient & to initiate care within first
few minutes of patient’s entry into the emergency facility. The emergency
physician had an obligation to determine who was waiting for physician
care & how critical the need was for that care.
EMTALA
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▪ In 1986, Congress passed the Emergency Medical Treatment and Active
Labor Act (EMTALA) that forbids Medicare-participating hospitals from
dumping patients out of emergency departments.
EMTALA
42 U.S.C.A. § 1395dd(a) (1992)
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▪ in the case of a hospital that has a hospital emergency department, if
any individual (whether or not eligible for benefits under this subchapter)
comes to the emergency department and a request is made on the
individual’s behalf for examination or treatment for a medical condition,
the hospital must provide for an appropriate medical screening
examination . . .
EMTALA Text Cases
▪ EMTALA Claim Against Hospital Valid
▪ Failure to Stabilize Patient
▪ Inappropriate Transfer
▪ Failure to Admit
▪ Patient Who Left
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▪ Stabalizing the Patient
EMTALA Text Cases -II
−Trahan v. McManus
▪ Who is responsible for Terry’s death?
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▪ Wrong Record: Fatal Mistake
▪ Terry was taken to the hospital after automobile accident. Upon
ordering discharge, the ED physician had not realized that he had
made a fatal mistake. The physician looked at the wrong chart in
determining Terry’s status, thus discharging Terry. Terry died at home
in his father’s arms.
Wrong Record: Fatal Mistake – II
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▪ The ED physician by his own admissions stated that he acted negligently
when he discharged Terry and that his actions led to Terry’s death.
Duty to Contact On-Call Physician
▪ Timely Response Required
▪ Failure to Contact On-Call Physician
▪ Physicians Fail to Failure to Respond
▪ Notice of Inability to Respond to Call
▪ Telephone Medicine Costly
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▪ Hospitals are expected to notify specialty on-call physicians when their
particular skills are required in the ED.
CASE: Telephone Medicine Costly
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▪ Lauren was taken to the hospital ED. Hospital personnel
contacted the physician by phone. He returned the call &
prescribed a Phenergan injection. He did not go to the
hospital & had not been given Lauren’s vital signs when
he suggested such an injection, & further failed to order
any blood or urine tests. Hospital records revealed that
Lauren’s glucose level was 507 at the time of admission.
Lauren’s went into respiratory failure & eventually died.
Futch v. Attwood
▪ Was the physician liable?
CASE: Yes!
▪ The defendant complained that the award of $98,000 was excessive.
▪ On appeal, the appellate court could not find that the trial court had erred
in concluding what sum was fair to both parties.
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▪ The trial court allocated $98,000 for the conscious pain & suffering of
Lauren.
Preventing ED Lawsuits – I
▪ Communicating to ensure complete & accurate picture of the patient’s
symptoms & complaints.
▪ Ensuring caregivers effectively communicating.
▪ Provide continuing education programs.
▪ Not taking lightly any patient’s complaint.
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▪ Courteous & prompt treatment
▪ Treatment regardless of ability to pay
▪ Triage – setting treatment priorities
▪ Establishing on-call roster procedures
▪ Providing consultation by specialists
Preventing ED Lawsuits – II
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▪ All patients must be treated.
▪ Hospital determines types of patients & levels of care they can safely
address.
▪ Knowing when to admit or transfer a patient.
▪ Provide follow-up instructions.
▪ Hospitals need to determine what types of patients & levels of care they
can safely address. If there are several hospitals in a community, they
must learn to communicate with one another & include emergency
medical services personnel in addressing transport & care issues.
CASE: IMPROPER TRANSPORT
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▪ If Hospital A has no neurologist, neurosurgeon, or stroke team &
Hospital B, 1-mile away has all of that plus a Level I trauma center,
would it be fair to say that a suspected stroke victim should be
transported to Hospital B?
Yes!
▪ Its is not just any hospital, it is the right hospital that saves lives.
▪ Under what circumstances would hospital B be the first hospital of
choice?
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▪ Taking the patient to hospital A raises both ethical and legal issues.
Laboratory Services
▪ Provides vital data
▪ Measures blood levels for toxicity
▪ Places & monitors instrumentation on patient units
▪ Provides education for lab & other disciplines as necessary
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▪ Monitors therapeutic ranges
Laboratory Services – II
▪ Provides valuable data utilized in research studies
▪ Serves consultation role
▪ Provides valuable data as to the nutritional needs of patients . . . .
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▪ Provides data on most effective and economical antibiotic for treating
patients
Failure to Detect Pap Smear Changes
−Sander v. Geib, Elston, Frost Prof’l Ass’n
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▪ Court determined evidence relating to negligence claims pertaining to
Pap tests taken more than 2 years before filing the action were
admissible because the patient had a continuing relationship with the
clinical laboratory as a result of her physician submitting her Pap tests to
the laboratory over a period of time.
CASE: Importance of Laboratory Results
Impending Stroke
▪ High Glucose Levels Not Addressed
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▪ Controlled Glucose Levels =
▪ Improved Recovery
▪ Fewer Deficits
LAB: Text Cases
▪ Test Results and Misdiagnosis
▪ Failure to Follow Recommended Transfusion Protocol
▪ Mismatched Blood
▪ Transfusion of Wrong Blood
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▪ Confusion of Laboratory Specimens
Medical Assistant
▪ Employment of medical assistants is expected to grow much faster than
the average for all occupations.
▪ Those in large practices tend to specialize in a particular area, under
supervision.
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▪ An unlicensed person who provides administrative, clerical, and/or
technical support to a licensed practitioner.
Nutritional Services
▪ Need to provide nutrition
▪ Nursing facility patient’s highly vulnerable
▪ Lambert v. Beverly Enterprises
▪ Patient suffered malnutrition
▪ Motion to dismiss case denied
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▪ Failure to do so can result in a lawsuit
Pharmacy: Medications
▪ Immense variety & complexity of medications.
▪ The pharmacist has become an essential resource in modern hospital
practice.
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▪ Impossible for nurses or doctors to keep up with the information required
for safe medication use.
FD Finds Safety Problems
at Specialized Pharmacies
−Lena H. Sun, The Washington Post, April 12, 2013
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▪ Federal inspectors have found dozens of potentially dangerous safety
problems at 30 specialized pharmacies, months after tainted steroid
shots made by a Massachusetts pharmacy triggered the worst drug
disaster in decades.
Common Prescription Errors
▪ Wrong patient
▪ Inappropriate drug ordered due to known drug allergies or drug-drug and
food-drug interactions
▪ Wrong dose
▪ wrong route
▪ wrong frequency
▪ transcription errors due to illegible handwriting or improper use of
abbreviations
▪ inadequate review of drug appropriateness
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▪ Wrong drug
Common Dispensing Errors
▪ Improper preparation of medication
▪ Dispensing expired medications
▪ Mislabeling containers
▪ Wrong patient
▪ Wrong dose
▪ Wrong route
▪ Misinterpretation of physician order
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▪ Failure to properly formulate medications
Common Documentation Errors
▪ Inaccurate transcription to medication administration record (MAR)
▪ Charted but not administered
▪ Administered but not documented on the MAR
▪ Discontinued order not noted on the MAR
▪ Medication wasted and not recorded
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▪ Transcription errors often due to
▪ illegible handwriting
▪ improper use of abbreviations
Control of Drugs
▪ Federal Controls
▪ State Regulations
▪ Storage of drugs
▪ Hospital Formulary
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▪ Controlled Substance Act
▪ Federal, Food, Drug & Cosmetic Act
Decreasing Med Misadventures:
Helpful Tips
▪ For clarity, do not use felt-tip pens.
▪ Abbreviations should be used per hospital policy.
▪ Do not write ambiguous orders.
▪ Always add a zero prior to a decimal.
▪ Hold orders should be accompanied by a time frame.
▪ Know about the med that you are prescribing.
▪ Administered by the proper route.
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▪ Be sure handwriting is legible; print if necessary.
Role of Pharmacists
▪ Drug-drug interactions
▪ Drug-food interactions
▪ Limited Duty to Warn
▪ Pharmacists cannot possibly warn caregivers & patients of every
potential danger of a drug.
▪ Warning patients – potential for overdose
▪ Refuse to honor questionable prescriptions
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▪ Duty to monitor patient’s medications
▪ Computer systems monitor for:
Role of Pharmacists – II
▪ Intravenous Admixture Service
▪ Duty to Monitor Patient’s Medications
▪ Warning Patients: Potential for Overdose
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▪ Dispensing and Administration of Drugs
Role of Pharmacists – III
▪ Limited Duty to Warn
▪ Failure to Consult with the Patient’s Physician
▪ Internet Pharmacy
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▪ Refusal to Honor Prescription
Physical therapy
▪ Evaluation of patient’s disability & rehab potential
▪ Treatment Modalities
▪ physical agents (heat, cold, ultrasound, electricity, water, and light)
▪ neuromuscular procedures
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▪ Art & Science of preventing & treating neuromuscular or musculoskeletal
disabilities
CASE: Interpreting Physicians Orders
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▪ Plaintiff alleged that defendant failed to exercise degree of
care & skill ordinarily exercised by physical therapists,
failed to heed his protests that he could not perform the
physical therapy treatments she was supervising, & failed
to stop performing treatments after he began to complain
he was in pain. Plaintiff’s expert testified defendant
deviated from standard of care by introducing a type of
exercise not prescribed by the physician.
−Pontiff, in Pontiff v. Pecot & Assoc.
Court’s Ruling
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▪ The appeals court found that the trial court was correct in its
determination that the plaintiff presented sufficient evidence to show that
this duty was breached & that therapist’s care fell below the standard of
other physical therapists.
Case: Neglect
▪ Court determined
▪ evidence supported a finding of resident neglect.
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▪ Refusal to allow patient to go to the bathroom
▪ prior to therapy
CASE: Termination
Contracted Services
▪ Hospital could terminate PT contracted services
▪ Hospital had right to terminate services
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▪ Hospital decided to establish hospital-based physical therapy program
Physicians Assistant
▪ Graduate of an accredited PA educational training.
▪ with the supervision of a physician.
▪ Scope of practice defined by each state.
▪ PAs responsible for own negligent acts.
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▪ Nationally certified and state-licensed to practice medicine.
Respiratory Therapist
▪ Failure to remove endotracheal tube
▪ Failure to properly restock the Code Cart
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▪ Multiple use of same syringe
Licensing
Healthcare Professionals – I
▪ Some professional groups establish their own minimum standards for
certification in those professions that are not licensed by a particular
state.
▪ Certification by an association or group is a self-regulation credentialing
process.
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▪ Recognition by a governmental or professional association that an
individual’s expertise meets the standards of that group.
Licensing
Healthcare Professionals – II
▪ Licensure refers to the process by which licensing boards, agencies, or
departments of the several states grant to individuals who meet certain
predetermined standards legal right to practice in a health care
profession.
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▪ Authority grants permission to a qualified individual to perform certain
specified activities.
Licensing
Healthcare Professionals – III
▪ Suspension & Revocation of License
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▪ procurement of a license by fraud
▪ unprofessional, dishonorable, immoral, or illegal
conduct
▪ performance of specific actions prohibited by
statute; and malpractice.
Licensing
Healthcare Professionals – IV
▪ Commonly stated objectives of licensing laws are to
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▪ limit & control admission to the different health care
occupation
▪ protect the public from unqualified practitioners by
promulgating & enforcing standards of practice
PROFESSIONAL MISCONDUCT
▪ Reporting medical misconduct
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▪ Sexual Improprieties
▪ Dentist
▪ Physician
▪ Psychiatrist
Helpful Advice for Caregivers
▪ Abide by the ethical code of one’s profession.
▪ Maintain complete medical records.
▪ Seek the aid of professional medical consultants when indicated.
▪ Inform the patient of the risks, benefits, and alternatives to proposed
procedures.
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▪ Do not criticize the professional skills of others.
Helpful Advice for Caregivers – II
▪ Authenticate all telephone orders.
▪ Be a good listener, and allow each patient sufficient time to express fears
and anxieties.
▪ Safely administer patient medications.
▪ Closely monitor each patient’s response to treatment.
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▪ Obtain a qualified substitute when you will be absent from your practice.
Helpful Advice for Caregivers – III
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▪ Develop & implement an interdisciplinary plan of care for each patient.
▪ Safely administer patient medications.
▪ Closely monitor each patient’s response to treatment
▪ Provide education & teaching to patients.
▪ Foster a sense of trust & feeling of significance.
▪ Communicate with the patient & other caregivers.
Helpful Advice for Caregivers – IV
▪ Provide education and teaching to patients.
▪ Communicate with the patient and other caregivers
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▪ Foster a sense of trust and feeling of significance.
REVIEW QUESTIONS
1. What was the reasoning for enacting the EMTALA?
3. Discuss why you think the prescribing, control, administration, and
monitoring of medications has become a major area of legal concern
for health care professionals.
4. Describe the difference between the certification and licensing of a
health care professional.
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2. Should medical advice be dispensed on the telephone? Explain your
opinion.
Chapter 11
Medical
Records
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LEARNING OBJECTIVES
▪ Describe the contents of medical records.
▪ Desciribe the importance of maintaining complete and
accurate records.
▪ Describe the advantages and disadvantages of electronic
records.
▪ Explain what is meant by the medical record
battleground.
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▪ Explain the ownership and who can access a patient’s
medical record.
Medical Record
Means of Communication
▪ Planning tool for patient care
▪ Document communication (e.g., progress notes)
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▪ Documentation of a patient’s
▪ Illness
▪ Symptoms
▪ Diagnosis
▪ Treatment
Medical Record
Means of Communication – II
▪ Protect legal interests of patient, org, & practitioner
▪ Continuing education
▪ Research
▪ Provide info necessary for 3rd-party billing
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▪ Provide database for use in statistical reporting
Ownership & Release of Records
▪ Ownership: Provider of Care
▪ Right to access
▪ Failure to Release
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▪ Request by Patients
Ownership & Release of Records: Privacy
Exceptions
▪ Requests: 3rd Parties
▪ Criminal investigations
▪ Substance abuse records
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▪ insurance carriers (for processing claims)
▪ medical research
▪ educators
▪ government agencies
Completion of Medical Records
Records Must Be:
▪ Legible
▪ Timely Written
▪ Cases:
▪ Failure to Record Patient’s Care
▪ Failure to Use Information
▪ Timely Completion of Medical Records
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▪ Accurate
Privacy Act of 1974
▪ Provide individuals access to records
▪ concerning themselves that are maintained by federal agencies
▪ to establish a Privacy Protection Safety Commission.
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▪ Enacted to safeguard individual privacy from the misuse of federal
records
HIPAA
▪ Health Insurance Portability & Accountability Act of 1996
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▪ Act to protect the privacy, confidentiality, & security of patient information.
HIPAA
KEY Provisions
▪ Patients must be informed of how personal information will
be used.
▪ Patient consent for release of info for marketing purposes
required.
▪ Patients can ask insurers & providers to take reasonable
steps to ensure their communications are confidential.
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▪ Patients able to access their record & request correction
of errors.
Documentation of Treatment
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▪ Continuing patient care
▪ Case: Accuracy of Medical Record Entries
Retention of Records
▪ Necessary to provide continuing patient care.
▪ Case:
▪ Destruction of Oncology Records
▪ Failure to preserve a patient’s records can lead to lawsuits.
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▪ Retention requirements can vary state to state.
Electronic Records
Advantages
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▪ Timely access to patient information
▪ patient demographics
▪ problems lists
▪ history & physical exams
▪ vital signs
▪ diagnostic test results
▪ consultant reports
Electronic Records
Advantages II
▪ Critical alerts
▪ out-of-range test values
▪ drug–drug & food–drug interactions
▪ computer-assisted diagnosis and treatment
▪ reminders for follow-up testing
▪ assistance in standardizing treatment protocols;
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▪ Order entries
▪ Medications
Electronic Records
Advantages – III
▪ Improving ability to timely share information with treating providers
▪ Reduced charting costs
▪ Support for clinical education & research
▪ Generation & transmission of electronic prescriptions
▪ Storage of medical records indefinitely
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▪ Improved productivity & quality
Electronic Records
Disadvantages
▪ Risk of lost confidentiality
▪ Increase in cyber crime.
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▪ Unauthorized disclosure of information.
HITECH
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▪ Health Information Technology for Economic & Clinical Health Act
▪ designed to promote widespread adoption & interoperability of health
information technology.
▪ Requires reporting of unsecured protected health information that
affect 500 or more individuals.
Medical Record Battleground
▪ Record should be complete & accurate
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▪ Not a tool for registering complaints between caregivers
Legal Importance of Records
Case Studies
▪ Records Authorship Questioned
▪ Medical Identity Theft
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▪ Communications Between Caregivers: Failure to Note an Order Change
Falsification of Records
▪ Documentation Falsified
▪ Objection to Record Notations
▪ Tampering with Records
▪ Erasures and Write Overs
▪ Rewriting and Replacing Notes
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▪ False Entries in Operative Report
Illegible Handwriting
▪ Harvard study found “penmanship was among the causes of 220
prescription errors out of 30,000 cases
▪ Case: Fatal Handwriting Mix-Up
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▪ Medical errors because of poor handwriting can lead to extended length
of hospital stays & death in some cases
Confidential & Privileged Communication
▪ Ordinary Business Documents
▪ Attorney-Client Privilege
▪ Joint Commission Reports Privileged
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▪ Cases:
▪ Release of Confidential Information
▪ Breach of Physician-Patient Confidentiality
Charting & Helpful Advice
▪ Complete & pertinent entries
▪ Legible entries
▪ Clear & meaningful entries
▪ Complete
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▪ Timely entries
Charting & Helpful Advice – II
▪ Avoid
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▪ defensive & derogatory notes
▪ erasures & correction fluids
▪ criticism
▪ complaints
▪ tampering with the chart
Charting & Helpful Advice – III
▪ Secure records pending legal action
▪ Entries made by others must not be ignored.
▪ patient care is a collaborative interdisciplinary team
effort.
▪ Entries made by health care professionals provide
valuable information in treating the patient.
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▪ Obtain legal advice
REVIEW QUESTIONS – I
1. What are basic purposes of medical record?
3. Medical record is sole property of the hospital & should never be
released. Discuss your opinion on this statement.
4. How long should patient records be maintained?
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2. Discuss advantages & disadvantages of computer-generated medical
records.

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