Medical Law and Ethics Ch 7 & 8

List the 5 C's of documentation

-Concise -Complete (and objective) -Clear (and legibly written) -Correct -Chronologically ordered

Who cannot give informed consent?

-Minors (except emancipated minors, married minors, and mature minors) -mentally incompetent persons -persons speaking limited or no english

How long do physicians usually keep records

-Usually 2-7 years after year of maturity -most physicians retain records indefinitely

Ways to secure electronic data

-appoint security officer to practice -passwords -risk assessment should include evaluating how each person protects their password -passwords shouldn't be posted -passwords shouldn't be divulged unnecessarily -appropriate firewalls, encryption, antivirus in place

What is a medical record?

Collection of data recorded when a patient seeks medical treatment

electronic data exchange (EDI)

the use of uniform electronic network protocols to transfer business info between organizations via computer networks

Health Insurance Portability and Accountability (HIPAA)

federal law passed in 96 to protect privacy and other health care rights for patients.

List the four categories of code sets

-coding for diseases, impairments, or other health probs -causes of injuries, diseases, impairments, and other health problems -actions taken to prevent, diagnose, treat, or manage diseases, injuries, and treat impairments -substances, equipment, supplies, or other items used to perform these actions

Electronic Health Record

-contain same information as any med record but electronic format -cautions regarding confidentiality include using -photocopiers, fax machine, computer and printers

List how to document a correction on a medical record

-draw a line through error -write or type info above or below or in margin -note why correction is made -enter date and time -have another person witness correction and initial if possible

Good Samaritan act

-give care in good faith -act within scope of practice -use due care under circumstances -do not bill for services

HIPAA covered entities

-hospitals/ academic medical centers -nursing home -hospices -pharmacies -physician practices -dental practices -chiropractor -podiatrist -osteopaths -alternative med practitioners -labs -health plan payers -health care clearinghouses

Basis for privacy laws

-info collected and stored should be limited to what is necessary to carry out function of business ro gov agency collecting info -once collected, access to info should be limited to those who need it to perform their jobs -personal info cant be released outside of organization w/o authorization -patient should know what info is being collected, and have opportunity to check accuracy of info

List 3 reasons medical information is usually released

-insurance claims -transfer to another physician -use in court of law

HIPAA Covered transactions

-physician submitting electronic claim to health plan -physician sending referral or authorization electronically to another phys., lab, or hospital -phys. sending patient identifying info to a billing service -health care provider that employs another entity, clearinghouse, billing agency,

List the information included with informed consent

-proposed mode of treatment -why treatment is necessary -risks involved in proposed treatment -available alternative modes of treatment and risks of these modes -risks involved if treatment is refused

Who owns the medical records?

-records are owned by the facility that created them -information records contain belong to patient -with signed release patients can usually obtain a copy

List the purposes of medical records

-required by licensing authorities for tracking, documenting, and maintaining patient communication -provide documentation of health from birth to death -provide foundation for managing patients health care -serve as legal doc. in lawsuit -provide clinical data for statistics, research, education

Types of HIPAA defined permission

-required disclosures -disclosures to patients -disclosure for treatment, payment, or health care operations -others' treatment, payment, operation -personal representatives -disaster relief organ. -incidental disclosure -public purpose -authorization -de-identification -limited data set

Special requirements for disclosure

-verification -minimum necessary -marketing -psychotherapy notes -policies and procedures consistent with notice of privacy practices -state laws

Which amendments include privacy of health care

1,3,4,5,9,14

treatment, payment, and health care operations (TPO)

A HIPAA term for qualified providers, disclosure of PHI to obtain reimbursement, and activities and transactions among entities. treatment means that a health care provider can provide care. Payment means that provider can disclose PHI to receive reimbursement health care operations refers to HIPAA-approved activities and transactions

Doctrine of professional discretion

A principle under which a physician can exercise judgment as to whether to show patients who are being treated for mental or emotional conditions their medical records. Decisions depends on physicians discretion on if such patients would be harmed by viewing their records

When is consent unnecessary

Emergency situations

de-identify

To remove from health care transactions all information that identifies a patient

rule

a document that includes the HIPAA standards or requirements

Confidentiality of Alcohol and drug abuse, patient records

a federal statute that protects patients with histories of substance abuse regarding the release of information about treatment

standard

a general requirement under HIPAA

permission

a reason under HIPAA for disclosing patient info

Notice of Privacy practices (NPP)

a written document detailing a health care providers privacy practices

HIPAA Legislation benefits

act helps workers keep continuous health insurance coverage for themselves and dependents when they change jobs, and protects confidential medical info from unauthorized disclosure or use. it was also intended to help curb rising cost of health care

Privacy

freedom from unauthorized intrusion

state preemption

if a states privacy laws are stricter than HIPAA state takes precedence

protected health information (PHI)

information that contains one or more patient identifiers

List items that can be used to identify a patient

name, zip code, D.o.b., date of treatment, phone number, fax, email, social security number, med. record number, health plan beneficiary number, birth certificate and drivers license number, vehicle identification number and license plate number, web site address, fingerprint and voice-print, photo

Consent

permission from a person, either expressed or implied, for something to be done by another

Fiduciary duty

physicians obligation to patients based on trust and confidence

designated record set

records maintained by or for a HIPAA covered entity

Health Information Technology (HIT)

the application of information processing, involving both computer hardware and software, that deals with the storage, retrieval, sharing, and use of health care info data, and knowledge for communication and decision making

doctrine of informed consent

the legal basis for informed consent, usually outlined in a states medical practice acts

Transaction

transmission of information between two parties for financial or administrative activities

code set

under HIPAA, terms that provide for uniformity and simplification of health care biling and record keeping