Medical Laws and Ethics: Module 4: Legal Issues Related to Medical Documentation

The Five Stages of Grief

"The five stages—denial, anger, bargaining, depression, and acceptance—are a part of the framework that makes up our learning to live with the one we lost. They are tools to help us frame and identify what we may be feeling. But they are not stops on some linear timeline in grief. Not everyone goes through all of them or goes in a prescribed order." Grief is the experience of responding to a past, present, or future loss. There are many ways to understand and respond to someone who is grieving. Understanding what grief looks like and how it materializes in real life is the first step to developing your own methods for responding to people who are grieving. Dr. Elisabeth Kübler-Ross in her seminal book on grief, On Death and Dying, opines that there are five stages of grief: denial, anger, bargaining, depression, and acceptance. According to Dr. Kübler-Ross' model, people who encounter loss will experience some or all of the five stages of grief. There are, however, a few important caveats: not everyone who experiences loss will go through all five stages of grief; the stages will not necessarily occur in order; and, in some cases, some or all the stages will repeat themselves. Nonetheless, the five stages listed below largely describe the experience of grief. Denial. In this stage, people who are grieving cannot or will not accept the loss. According to Dr. Kübler-Ross, "[d]enial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned." People may feel as if they are in a bad dream or that the loss is not really happening. They often feel emotionally numb or in shock. People who experience this stage use it to temporarily manage the initial shock of the loss. Anger. Once people have accepted that the loss has occurred or will soon occur, they may begin to experience anger. Here, people are facing the pain of the loss and the unfairness of it. People in the anger stage may become angry at the person who has died, the disease that is at issue, a higher power, or life in general. Anger can show itself in several different ways. Understanding that anger takes many forms and has many targets will help you develop methods for responding to people in this stage. Bargaining. In this stage, people seek to bargain to somehow undo the loss. For example, someone in this stage may make a promise to a higher being to be a better person if only the diagnosis of terminal cancer is reversed. During this stage, people will focus on what could have been done to avoid the loss. Bargaining, however, seldom provides the resolution that people need, especially when it concerns death. Depression. Once the reality of the loss sets in, people realize that anger and bargaining will not change the loss. At this point, people may then find themselves feeling depressed. People in this stage may cry, change sleeping or eating habits, or withdraw from life activities. Dr. Kübler-Ross explains that "[i]t's a sort of acceptance with emotional attachment. It's natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality." Acceptance. People find themselves at a stage of acceptance when they have experienced their initial emotions, can accept the reality and finality of the loss, and are once again able to continue in their daily life. In this final stage of grief, people may still feel sad, but they can start moving forward with their lives. Dr. Kübler-Ross notes that "[p]eople dying can enter this stage a long time before the people they leave behind, who must necessarily pass through their own individual stages of dealing with the grief."

Stage 1—Eligible Professional Menu Set Objectives

(1) Implement drug formulary checks. (2) Incorporate clinical lab-test results into EHR as structured data. (3) Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. (4) Send patient reminders per patient preference for preventive/follow-up care. (5) Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within four business days of the information being available to the EP. (6) Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate. (7) The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. (8) The EP who transitions their patient to another setting of care or provider of care or refers his or her patient to another provider of care should provide summary care record for each transition of care or referral. (9) Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice. (10) Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice.

Stage 1—List of Eligible Professional Core Objectives

(1)Use CPOE for medication orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local and professional guidelines. (2) Implement drug-drug and drug-allergy interaction checks. (3) Maintain an up-to-date problem list of current and active diagnoses. (4) Generate and transmit permissible prescriptions electronically (eRx). (5) Maintain active medication list. (6) Maintain active medication allergy list. (7) Record all of the following demographics: (A) Preferred language (B) Gender (C) Race (D) Ethnicity (E) Date of birth (8) Record and chart changes in the following vital signs: (A) Height (B) Weight (C) Blood pressure (D) Calculate and display body mass index (BMI) (E) Plot and display growth charts for children 2-20 years, including BMI (9) Record smoking status for patients 13 years old or older. (10) Report ambulatory clinical quality measures to CMS, or in the case of Medicaid EPs, the States. (No longer core objective but still required) (11) Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule. (12) Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies) upon request. (13) Provide clinical summaries for patients for each office visit. (14) Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

Steps for Proper Records Management

1. Read accurately and spell names correctly. 2. Print or write legibly with black ink. 3. Record information as soon as possible. 4. Make corrections by drawing one line through the error. 5. Keep charts neat and file a timely manner.

The Purpose of Records

A complete and accurate medical record is a combination of the patient's personal information, personal medical history, known family history, social habits, medications, occupational exposures, and different types of testing performed. When any one of these is absent, the provider is without all the data needed to make an accurate diagnosis and plan further care. The medical assistant plays an essential role in compiling and maintaining all the elements of a complete medical record to facilitate the provider's evaluation and manage the patient's course of treatment. The patient's personal information contains demographic information, that includes gender, ethnicity, religion, age, marital status, occupation, insurance information, and more. Gender is relevant to certain types of disease processes and treatments, as is ethnicity. Persons from different ethnic groups might share a genetic propensity toward certain diseases or disorders. Some ethnic and religious groups have dietary practices that can prevent them from accepting specific types of medical care, and some practices can even interfere with prescribed drugs and treatments. Age is important when evaluating diseases of childhood, adolescence, childbearing years, and the older adult. Marital status, children, and living arrangements provide information regarding potential stressors as well as support systems. Occupation and insurance information can indicate exposures to environmental hazards or toxins. The medical record serves as a way to maintain and document the course of medical evaluations, treatments, and changes in condition. Charting progress lays out a chronological account of the patient reports, provider's evaluation, prescribed treatment, and responses to treatment as well as the need for further follow-up. Recording communications that occur between provider and other health care professionals further enforces continuity in the patient's care and helps eliminate incompatible therapies or duplication of efforts that can lead to unnecessary expense or even overdoses of medications. Copies of all reports from various providers, tests, diagnostic procedures, or interventions should be carefully maintained and shared among providers. In addition to maintaining optimal patient care, a complete and accurate record provides legal protection for both the patient and the provider. To support a patient's account of injury, the provider would need to refer to the medical record. The provider would also require a complete medical record if he or she needed to defend him- or herself against legal action brought by a patient. No matter the reason for the requested records, a patient must provide a signed authorization before any information may be released. The authorization must specifically indicate who should receive the information and for what purpose it will be used. In the case of mental health records, substance abuse treatment, or genetic testing, additional authorization is required in addition to a general release of information. The medical record may also be used for insurance purposes. Patient records help verify that claims filed for payment are based on accurate and appropriate treatments as approved through the contract between the company and the provider and meet federal laws that address reimbursement. Insurance companies may send a representative to perform periodic chart audits (inspections) of patients insured by the company. Medical offices receive an overall grade that reflects the thoroughness and quality of their recordkeeping. Offices that consistently score low jeopardize future contracts with those insurance companies. Records can also be helpful in conducting research. A searchable database of patient records can help identify patients who might benefit from inclusion in clinical research protocols. Clinical trials can offer the advantage of a treatment otherwise unavailable to the patient and additional care he or she might not have otherwise received.

Release Forms

A patient's in-person oral request or telephone call is insufficient to properly authorize the release of health records. The request must be in writing. And, when the information requested is disclosed, it must be accompanied by a instructions that forbid its re-disclosure to others who are not authorized to receive it. To compel, or force, the production of health records, a subpoena is necessary. A subpoena is a command to appear at a certain time and place to give testimony on a certain matter. The particular type of subpoena used for documents or objects is called a subpoena duces tecum. It identifies the records that are requested in court. Legal subpoenas do not automatically require the release of all requested health information. When sensitive information about patients and other persons has been requested without consent of the parties, the issues can be discussed with the judge and attorneys. The judge may then make the decision to review the material privately to determine whether it should be allowed into evidence.

Past Medical Records

A routine activity in admitting new patients to a practice is to request medical records from prior providers for continuity of care and to provide a basis of comparison for new events. By having a baseline from which to work, the provider can avoid duplicating unnecessary evaluations, tests, and treatments that have previously failed. Not only does this improve the level of care and efficiency by decreasing the time required to arrive at an accurate diagnosis, but it also prevents subjecting the patient to unnecessary discomfort and expense while keeping insurance costs down. Even though patients have a legal right to their medical information, the chart belongs to the provider or the practice. A patient should never leave the office with a chart. Some patients might have information in the medical chart that could be damaging to them if they read it. For example, mental health notes or diagnoses that the patient does not have the capacity or educational ability to understand can cause emotional harm. A provider's order is required before any information in the chart can be released. The provider will indicate which reports and comments are authorized to be copied for release to the patient. Copies or written summaries of a patient's health records are usually the format chosen to send to another provider or health care facility. Progress notes can be electronically attached to the referral in the EHR.

Correspondence and Referrals

All correspondence received, whether medical or financial, concerning the patient should be maintained in the record. Referral or follow-up letters from specialists, informational or request-for-information letters from insurance companies, and any correspondence from the patient should be filed in the patient's chart as soon as possible after it is received. In an EHR, correspondence is scanned and uploaded or electronically received into the patient's chart for easy retrieval. Referrals and authorizations in the EHR are made simple, with referring to/from providers included in the database, thus eliminating the need to keep a separate list of providers and specialists, paper forms, and having to fax, mail, and file the forms. Authorizations can be automatically included in the referral.

No matter the reason for the requested records, a patient must provide a signed authorization before any information may be released. The authorization must specifically indicate who should receive the information and for what purpose it will be used. In the case of __________________, additional authorization is required in addition to a general release of information.

All of the above; mental health records, substance abuse treatment, genetic testing

Health Care Proxy

All states have enacted legislation empowering the patient to use a health care proxy. Sometimes known by other terms such as a directive to physicians and family or surrogates or some other title, in every case, the legislation provides that the document shall do the following: Identify the principal and the health care agent; Express the intention of the principal that the health care agent has authority to make health care decisions on behalf of the principal; Describe any limitations on the authority of the health care agent; Indicate that the authority of the health care agent to make health care decisions becomes effective upon a determination of incapacity; and Be revoked by notifying the agent or health care provider orally, in writing, or by any other act evidencing specific intent to revoke; by execution of a subsequent health care proxy; or by divorce or legal separation of the principal and spouse when the spouse is the agent. Most incompetent patients in need of life-sustaining treatment have not executed an advance directive. In this situation, it has become standard medical practice to seek consent from family members of incompetent patients. The President's Commission suggests the following: The family is generally most concerned about the good of the patient. The family will also usually be most knowledgeable about the patient's goals, preferences, and values. The family deserves recognition as an important social unit that ought to be treated, within limits, as a responsible decision maker in matters that intimately affect its members. Especially in a society in which many other traditional forms of community have eroded, participation in a family is often an important dimension of personal fulfillment. Since a protected sphere of privacy and autonomy is required for the flourishing of this interpersonal union, institutions and the state should be reluctant to intrude, particularly regarding matters that are personal and on which there is a wide range of opinion in society.

Fabricating Health Records

Altering health records modifies the content of the record, and fabricating records means inventing facts. The motive is typically to cover up an error or wrongdoing. The court upheld the denial of unemployment benefits where the employer terminated the employee for fabricating a patient's medical record. The court found that credible testimony proved that a patient's complaint that the employee had never visited the patient despite making a health record entry to the contrary.

Acceptable Method of Making Changes in Health Records

Although maintaining the record perfectly should always be the goal, it is important to recognize that incorrect entries may happen. Most EHR systems track each entry by user, date, and time. So, if a mistake is made and the record needs to be changed, the original error will remain but there will be an addendum with the correct information. When an error occurs with a paper chart, cross out the mistake, initial and date it, and then write the correct information. It is highly inadvisable to use correction fluid or some other method to try to hide the mistake. There are occasions when making a change in a patient's records is necessary. If the changes are made while the patient is under treatment, they may be accepted as rewritten or amended. But if the changes are made beyond a reasonable period of time following discharge, particularly after a physician or hospital is on notice of a potential lawsuit, changes in the health record are almost always serious and raise red flags. It is the responsibility of individuals charged with keeping health records to be accurate. They must bring any error in record keeping to the attention of the physician at the time it is discovered, as well as any ambiguous section that may affect the reader's understanding. It is the physician's responsibility to correct his or her own error. Keeping good notes is as important to the physician as the diagnosis. If the record keeper is in dispute with a physician, the facts should be recorded and reviewed by a neutral third professional. The physician is ultimately responsible; the assistant is responsible only if negligent in the performance or omission of assigned duties, or if conspiring to defraud.

Advance Directives

An advance directive asserts an individual's right to accept or refuse treatment and gives direction to relatives, friends, and medical professionals. The directive is necessary, according to former Senator John C. Danforth, R-MO, an Episcopal clergyman, because "[m]edical technology has outstripped ethics. For too many thousands of people, the end of life is a nightmare... [It is] turned over to technocrats whose job it is to eke out every last moment. This constitutes playing God by medicine." Supporting this position, and at the same time giving insight into the physician's behavior, James H. Sammons, former executive vice president of the American Medical Association (AMA), adds, "From the day [physicians] enter medical school they are taught to cherish and preserve life... While physicians should never directly cause death, they must always act in the best interest of the patients, and that sometimes includes allowing them to die." Advance directives can resolve many of the controversies that arise in situations where ethics, law, and medicine collide. Consider the following: Terri Schiavo, a 41-year-old brain-damaged woman, was the subject of a national right-to-die legal battle. Ms. Schiavo collapsed in her home due to heart failure that led to severe oxygen-deprivation brain damage. Ms. Schiavo's parents, the Schindler's, fought to keep her feeding tube in while Ms. Schiavo's legal guardian, her husband, fought to respect her verbal wish not to be put on life support. The legal dispute between Ms. Schiavo's husband and her parents was exceptionally bitter. The legal battle included legislation passed by Congress that placed the dispute in the federal court system, as well as several appeals to the U.S. Supreme Court, who declined to hear the case. Once doctors removed the feeding tube that had kept her alive for more than a decade, it was fewer than two weeks before Ms. Schiavo passed. In the Terri Schiavo case, the court reaffirmed the substitute judgment requirement and found that it was based on clear and convincing evidence. In doing so, it allowed the removal of the feeding tube based on permitting her husband to become the decision maker and deciding that he was taking into account her value system and personal belief, as well as her earlier statements about medical treatments. The question was not whether the state had the right to prevent the removal of the tube but that it could not do so without clear and compelling evidence that she would make that same decision if so able. Advance directives are a result of the need for evidence. There are three major forms of advance directives: living will, durable power of attorney, and health care proxy.

Patient Access to Health Record

An issue of chronic aggravation between the public, their representatives (lawyers), and the medical establishment is gaining access to health records. HIPAA protects the privacy of patient's medical information, and it also gives patients the right to access much of the information contained in their health records. Physicians disagree about whether patients should have access to their own records. Some believe that there is the possibility of misinterpretation by the patient; others are of the opinion that a little knowledge can be more dangerous than no knowledge at all. Legal commentators view patients' access to their own records cynically, observing that almost everyone except the subject of the records can know what is in them. HIPAA requires that patients have the right to see their records, to obtain copies, and to make corrections in them. Physicians who do not support a patient's direct access to health records comment that there may be information in the records that the patient or members of the family should not see; for example, confidential information on past pregnancies, abortions, sexually transmitted diseases, or mental illness. Artificial insemination presents ethical dilemmas in that the availability of the record to the family affects the woman's privacy regarding conception; on the other side of the issue, there is the responsibility of the physician to maintain an accurate record as well as to preserve information for the future benefit of the child. HIPAA requires, however, that certain health information be provided regardless of the provider's wishes. In very limited cases, a health care provider may refuse to provide a patient with certain information. Unreviewable grounds for denial (45 CFR 164.524(a)(2)): The request is for psychotherapy notes, or information compiled in reasonable anticipation of, or for use in, a legal proceeding. An inmate requests a copy of her PHI held by a covered entity that is a correctional institution, or health care provider acting under the direction of the institution, and providing the copy would jeopardize the health, safety, security, custody, or rehabilitation of the inmate or other inmates, or the safety of correctional officers, employees, or other person at the institution or responsible for the transporting of the inmate. However, in these cases, an inmate retains the right to inspect her PHI. The requested PHI is in a designated record set that is part of a research study that includes treatment (e.g., clinical trial) and is still in progress, provided the individual agreed to the temporary suspension of access when consenting to participate in the research. The individual's right of access is reinstated upon completion of the research. The requested PHI is in Privacy Act protected records (i.e., certain records under the control of a federal agency, which may be maintained by a federal agency or a contractor to a federal agency), if the denial of access is consistent with the requirements of the Act. The requested PHI was obtained by someone other than a health care provider (e.g., a family member of the individual) under a promise of confidentiality, and providing access to the information would be reasonably likely to reveal the source of the information. Reviewable grounds for denial (45 CFR 164.524(a)(3)). A licensed health care professional has determined in the exercise of professional judgment that: The access requested is reasonably likely to endanger the life or physical safety of the individual or another person. This ground for denial does not extend to concerns about psychological or emotional harm (e.g., concerns that the individual will not be able to understand the information or may be upset by it). The access requested is reasonably likely to cause substantial harm to a person (other than a health care provider) referenced in the PHI. The provision of access to a personal representative of the individual that requests such access is reasonably likely to cause substantial harm to the individual or another person. HIPAA also provides guidelines on what healthcare providers can charge patients for copies of their records. And, while states may pass laws that include costs that are less than those set forth in HIPAA, a state may not pass a law that allows for higher charges for patient records than HIPAA allows.

Medications

Any medication administered in the office is documented in the medications section of the chart. A complete medication entry includes the prescriber, the medication name, dose, frequency, site or route of administration, special preparation if applicable, time given, and any observation period following administration and patient's response to the treatment. In the case of vaccines: lot numbers, manufacturer name, and expiration date are also required information to be included in the record. Copies of prescriptions are also to be included as part of the chart. Whether provided as a hand-carried prescription, mailed to the patient, called or faxed to a pharmacy, or sent electronically, a record of all prescriptions given to the patient is essential to maintaining a complete patient record. Some practices prefer to keep a running log of prescriptions and when they are refilled or discontinued, which should also be maintained in this section. It should always be clear how the prescription was provided for other office personnel who review the chart to verify information, for instance, if a pharmacy calls with questions or a patient loses a paper prescription and requests a duplicate.

Capacity to Consent to Release of Information

Any patient who has reached the age of majority can consent to the release of health records. If a former patient is dead, the executor, administrator, or personal representative may release the record. If an adult patient is temporarily unable to consent, a court-appointed guardian has authorization. If an attorney is authorized by a patient to view a record, the patient need not be of sound mind at the time the decision to consent is made. In an emergency, a record may be released to the extent necessary without consent, because the emergency creates the power to act. Minors have particular problems with regard to the release of medical information. In a drug abuse or sexually transmitted disease diagnosis, only the minor involved can release the record, even to his or her parents or guardians. Normally, a parent or guardian can release the minor's records until the minor reaches majority. If one parent has been awarded custody of the minor, it is preferable to get that parent to release the medical information. The mature minor doctrine allows minors to release their records under certain circumstances such as when they are living away from home, self-supporting, or married. Under certain conditions, when a minor knows the nature, quality, and consequences of his or her actions, a minor can authorize the release of a health record.

Do-Not-Resuscitate Orders

As a result of the treatment of cardiopulmonary arrest with cardiopulmonary resuscitation (CPR), patients may be literally brought back to life after the traditional signs of a death have appeared. Whether CPR should be used on every patient is a question that haunts institutional professionals. This decision remains the province of the patient when they have executed an advance directive that includes an order to the physician not to resuscitate, a DNR order (in some states, referred to as a directive to physicians). It is estimated that approximately 80 percent of the two million people who die in the United States each year die in institutions. Each institution has professionals trained to respond to death with CPR. Although awareness of the legal need to have DNR orders in effect, if that is what is desired, has increased, clear guidelines for making those wishes known have not been well established. This can lead to action that is not in accord with the patient's wishes. A DNR order only works if the health care provider knows that it exists.

Release of Information to Attorneys

Attorneys need information from health records under many circumstances. If there is likelihood that medical malpractice charges will be brought against a physician, an attorney will usually ask to examine the records before going to court. By responding indifferently to a lawyer's request for records, a physician frequently causes problems. The attorney may find that it is more efficient to file the lawsuit and engage in formal discovery than to fight with a doctor for the records. This attitude hardens feelings between attorneys and physicians. Health records cannot be withheld pending payment of the patient's bill to a physician or a hospital.

Advantages of Using an EHR

Availability of a searchable database that records patients' demographics, allergies, lab results, and improved accessibility of the record to health care providers. Radiology and laboratory departments that can transmit results directly to the provider, reducing the time to treatment and notification of critical values. Electronically entered prescriptions that minimize errors related to illegible handwriting and reduce the time for prescriptions to be available to the patient. Software screens medications for interactions and allergies, decreasing the chance of an adverse reaction. Aiding in reminding the health care provider when routine testing should occur, such as mammography, vaccinations, and cardiovascular procedures. In a multispecialty facility or practice, facilitating coordination of care among providers and eliminating duplicate or incompatible testing and treatment. Chart notes that can be available immediately when a patient needs a referral or consultation with another provider. Voice recognition software that improves availability of printed records and decreases costs by eliminating the need for transcribing dictated notes. Assigning CPT and ICD codes at the time of the visit, streamlining the process of filing insurance claims. A photograph of the patient, which can be included in some software applications to ensure that the correct patient's record has been selected. Trending that might also help identify problems that might not be identified as early as when using traditional paper records. Although the EHR does not completely eliminate the necessity for paper records, it does decrease it substantially. The use of EHRs can streamline efficiency of health care, billing, and personal information security. Electronic records can also improve the health of an entire population by providing an accessible platform for deriving information that can help identify trends such as childhood obesity or flu epidemics. The provider and staff of a practice must, however, take all necessary precautions to ensure the security of electronic information and guard against its unauthorized access or use.

CHEDDAR

CHEDDAR is the acronym for chief complaint, history, examination, details, drugs/dosages, assessment, and return visit. Chief complaint: This is the presenting problem and should be recorded in the patient's words. Any unusual descriptions should be placed in quotation marks. A report of "just not feeling well" should be qualified further. Whether a complaint of illness or injury, as much subjective information should be obtained as possible to include location of the pain; radiation to any areas; quality: sharp, dull, throbbing, aching; severity assessed using a pain scale of 1-10 or, for children, a Wong-Baker faces scale; associated symptoms; aggravating factors; alleviating factors; and the time and onset of the symptoms. History: A list of the patient's prior medical history, including systemic problems; injuries; surgeries; allergies to food, environmental triggers, or medications; social habits such as smoking and alcohol use; safety measures observed such as bicycle helmet and seatbelt use; exercise habits; and any other health maintenance. This is also an area in which to include any relevant family history. Examination: This section is for objective findings of the examiner. Include responses to moving the patient or the patient's inability to perform a given task due to a cognitive or physical disability and whether these deficits are baseline for the patient, depending on prior history. Details of problems and complaints: Results of additional testing may be placed here in a separate section. Drugs and dosages: A comprehensive list of ALL medications, both prescription and over-the-counter drugs, as well as any herbal remedies or illicit substances used. Patients might not be forthcoming or volunteer information regarding nonprescribed use of substances but will often provide details when asked for further information. Assure them that the information is confidential. However, all information is obtainable in the event of legal proceedings, so if information is provided, it should be recorded accurately. Assessment: After obtaining all relevant data, a diagnosis or assessment can be made and appropriate testing and treatment can be prescribed. Return visit: Indicate when and if a return visit is required for follow-up or for routine health maintenance.

How do EHRs change the way amendments to records are made?

Changes to records are now automatically reflected as an amendment and marked with the user's name and time and date of the amendment.

Which is NOT a form of an advance directive?

Consideration

Credibility of the Health Record

Credibility of a health record refers to whether the information recorded in the record is believable. An article written for lawyers informing them how to recognize a good medical malpractice case (one they can win) stated the following: If you take on a case where the doctor or the hospital changes something in the records, you will need less than the usual quantum of fault to prevail before a jury. The same is true if a record or x-ray is missing. Even a change that the doctor argues was made for a good faith reason or a record lost with the explanation, "fire," "flood" or "robbery," will suggest to the jury that there was a guilty motive afoot-and there probably was. Even though the above article was written before the widespread use of EHR, the premise remains valid and true today: If a health record has corrections, amendments, modifications, changes, or even misspelled words, it will raise suspicions. The credibility of the health record is crucial in the defense of a physician, medical facility, or employee. Even though the above article was written before the widespread use of EHR, the premise remains valid and true today: If a health record has corrections, amendments, modifications, changes, or even misspelled words, it will raise suspicions. The credibility of the health record is crucial in the defense of a physician, medical facility, or employee. Health information is needed to try cases in nearly every area of law. When a lawyer meets with a client who has a complaint about medical care, the first step is to obtain all health records available and have them reviewed by an independent physician. The second physician's evaluation may prompt the attorney to further investigate the potential malpractice claim or to explain to the client why there is no evidence of malpractice. Sometimes attorneys find that they can settle with a potential defendant or the insurance company before filing a malpractice suit. This prelawsuit settlement usually happens when the health record has credibility issues. The credibility of the record-keeping procedure is subject to question when investigation reveals delayed filing of laboratory test results, incomplete files, illegible records, altered or fabricated records, or the loss or concealment of information.

Introduction

Despite the changes in the way a health record is kept, the foundational elements remain intact, including privacy, accuracy, timeliness, and reliance. The medical assistant is one of many care providers who manage patient health records. A medical record, also referred to as a health record, is a recorded collection of data on a patient. It includes past history, a statement of the current problem and diagnosis, and the treatment procedures used to solve the problem. Health records are created for many reasons, including the following: Records are often required by licensing authorities; records may contain information required by patient's insurance companies to pay claims; records are essential for communicating important data to all those who participate in a patient's care; records create a legal document to record and substantiate a standard of care; and specific records and pieces of data may be required by physicians' liability insurance. The move from paper charts to electronic health records (EHRs) has been one of the most significant changes in health care. Federal legislation that penalizes Medicare providers who continue to use paper charts has accelerated the transition to EHRs. The Health Information Technology for Economic and Clinical Health (HITECH) Act has created incentives for using EHRs, as well as penalties for not using them. Largely due to the data available from EHR, the health record is increasingly being used to determine the necessity for and the quality of health care. This is reflected in the greater use of the health record by health maintenance organization (HMO) peer review teams and insurance company audits. In addition to the fact that insurer reimbursement may depend on adequate documentation of services provided, the quality of a health care provider's health records often tells a lot about the quality of the practice.

Charting in the Patient Record

Each office has its own method of charting patient information during visits. In some practices, the medical assistant might record the findings of a physical examination as it is being completed, and in others, the provider might write or type all physical findings and progress notes during or immediately following the visit. If dictation is still used rather than EHR or voice recognition software, the progress note must be transcribed as soon as possible into the desired format with the time and date, placing the completed report in the patient's chart with a notation indicating that the report was transcribed and for whom—for example, "As dictated by Dr. H. G. Brown." Most dictated reports also bear a disclaimer stating that the report has or has not been reviewed for accuracy following dictation. In the early 1970s, Lawrence L. Weed, M.D., a professor of medicine at the University of Vermont's College of Medicine, originated a system of recordkeeping for patients that he named the problem-oriented medical record (POMR). Progress notes are organized and entered based on where they came from, whether from a provider, laboratory, or other source. The POMR record begins with the standard database information, including patient profile, chief complaint, review of systems, physical examination, and laboratory reports. Another page lists chronic problems, with dates of service for each problem. Finally, another section contains information such as medication lists, preventive care lists, and education information that has been provided to the patient. This enables the provider to review at a glance the patient's past history without having to read through each individual entry of the progress notes. When using paper records, the provider can make an overall assessment of the patient's health status to date. It works especially well in group practice settings because it promotes the continuity of patient care among the group members. This same information is incorporated into the platform of EHR systems. When a practice using paper charts converts to electronic health records, the problem list is a key source document from which information is abstracted into the new electronic chart.

Electronic Health Records

Electronic medical records (EMRs) are patient records in a digital format. Electronic health records (EHRs) refer to the interoperability of electronic medical records, or the ability to share medical records with other health care facilities. The Health Information Management Systems Society (HIMSS) provides a further distinction and definition of EHRs. EHRs provide improved management of patient records and facilitate more efficient billing for services. They also enable providers within an institution or system to use interactive flow sheets and develop customized order sets that can be great timesavers. EHRs offer the long-term capability not only to streamline medicine within facilities or systems but to provide continuity and emergency access to patient information when the patient is in a locale away from regular providers, as on vacations or business trips. A nationalized system would facilitate the harvesting of broader sets of data used to evaluate public health problems over a population and subdivide the results into various smaller sets. This can be applicable to environmental exposures such as air and water pollution, dietary influences of different regions, propensities for cancers across a region or population, and many other factors. Such a national concept regarding health records is not without critics. Data breaches and loss of privacy are of great concern to many. When President George W. Bush addressed the American Association of Community Colleges' annual convention in 2004, he commented that the United States was behind the times regarding patients' records. He remarked that the current health care system still used paper files and still dealt with the multitude of problems associated with paper, including the resulting threats to security of the information contained in personal health records. Since that time, the federal government has provided incentives for medical practices to convert to electronic health records through approving projects that encourage the implementation of such technology in medical practices.

Determination of Death

Ethical, legal, and medical issues arise that require a thorough analysis of the question, "When is a person is dead?" The Uniform Determination of Death Act (UDDA) was a response to that question. The UDDA is a model act, which is intended to be a starting point for state legislations that want to adopt it. The UDDA defines the medical determination of biological death, and it has been adopted by all states with very few modifications. The UDDA provides the following definition of death: "[a]n individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards."

Euthanasia (mercy killing)

Euthanasia, Greek for "good death," usually refers to an act in which one person kills another, at the request of and for the benefit of the one who dies. Suicide is the taking of one's own life. There is a blurring of the terms assisted suicide and euthanasia. Euthanasia—mercy killing, or actively assisting someone to terminate their life at their request—is not a new subject. As far back as Hippocrates, "the physician is discouraged from invading the atrium of death" and instructed that, in certain circumstances, "attempts to cure must yield to attempts to comfort." Hippocrates' treatise The Art instructs physicians "(1) to do away with the sufferings of the sick, (2) to lessen the violence of their diseases, and (3) to refuse to treat those who are over mastered by their diseases realizing that in such cases medicine is powerless." There are many arguments made against euthanasia: There could be a mistake in diagnosis. There may be difficulty in determining if euthanasia is voluntary—for example, where there is an undue influence exerted on the patient by a member of the family and/or beneficiary of a will for financial reasons. It could lead to a slippery slope; for example, with the growth of managed care, there may be more financial pressure to hasten death for those who are elderly, uneducated, on welfare, or disabled. Altering the role of physicians to include the practice of killing patients would bring about a psychological upheaval in the physician-patient relationship, and patients would become less trustful of their physician's role as healer.

Situations Where the Determination of Death Is Crucial

Executing wills and distributing estates A deceased person's will or intestate distribution cannot be made without a determination of death. Life insurance Life insurance policies require a determination of death before they pay out on the policy. Tort lawsuits Civil lawsuits that seek to recover damages for someone's death requires a determination of death. Organ donation A determination of death is required to allow for the harvesting and use of a deceased person's organs. Criminal matters involving death A determination of death is required to prosecute homicides.

Assessing the relative merits of the living will and the durable power of attorney for health care, the AMA finds that the living will can cover a broader range of illnesses than the durable power of attorney, which is often linked to situations of terminal illness when death is imminent.

False

Assisted suicide means an act done with intent to kill the victim.

False

If your physician's office is on notice for a potential lawsuit, you should alter the medical record to avoid litigation.

False

Federal law determines who owns a patient's health record.

False State law determines who owns a patient's health record.

A Security Rule within HIPAA mandates that not only the privacy of medical records but also the security of the records must be guaranteed. Which of the following would not be considered one of the four core areas of compliance?

Have policies and procedures in place to protect against every possible anticipated, known, unknown, impermissible uses, or disclosures.

Incomplete and Error-Filled Records

Health records must be accurate, complete, and correct. In the worst case scenarios, these types of mistakes in health records can have fatal results. In less severe cases, health record mistakes can damage a health care provider's reputation. Consider how you would feel if you were the patient in the following real-life example: Marilyn Mullins, 62, said she was shocked when she received a note from a chaplain at Sentara Martha Jefferson Hospital that said she had died... A hospital chaplain called Mullins with an apology and explained that a technical error caused the mistake. The hospital said a secretary accidentally checked the box for deceased patient instead of checking discharge to home.

Access to the Health Record

Hospitals and physicians should have a written policy on file detailing the procedures for releasing patient information. The policy must reflect federal law, and, if applicable, state law as well. In certain states, legislators have given the patient, the patient's physician, and/or the authorized agent the right to examine or copy the health record. In other states, judicial precedence has been set for those who base the right to examine the record on the patient's rights. There is general authorization for the physician or hospital to release information to insurance companies about patients submitting third-party payment claims. In addition, office records, as well as hospital records, are subject to inspection by an attorney authorized by the patient to examine them for use in possible litigation against either the physician or a third party. When a patient submits a claim to litigation, the authorization is not clear-cut and must be determined on an individual basis, but a patient cannot use the privilege as a sword and a shield. Patients are often required to submit to a physical examination before receiving benefits such as life insurance or welfare, participating in school athletics, obtaining a marriage license, or employment. In these situations, the patient consents implicitly or expressly to the sending of a truthful record to the third party. For example: Following a physical examination, the physician disclosed to a patient's employer that the patient had a long-standing nervous condition, despite the patient's express orders not to release such information. The disclosure caused the patient's dismissal. The court found that the duty for the physician to maintain confidentiality was qualified and depended on the context of the patient-physician relations. The physician was authorized to release the information.

Altered Health Records

If a record is damaging to a physician, he or she may be strongly tempted to change it. The use of EHR has, however, changed the way someone might alter a health record. With EHR, any changes to a record will be reflected as an amendment and be marked with the user's identification and time and date of the amendment. For any alteration to be plausible, all other people involved—physicians, nurses, administrators—must go along with it. Somewhere along the line the chain is almost bound to snap. Altered records demonstrate the defendant's consciousness of wrongdoing and strongly establish liability. If a jury learns that a physician has intentionally altered a record for improper reasons, they will award much larger damages. Insurance companies are well aware of this. It is no coincidence that when a medical malpractice case involves altered records, defense lawyers will advise their clients to settle the case. A 23-year-old woman was admitted for delivery of her first child and was administered a spinal anesthetic by the obstetrician. Her chart indicated that her blood pressure was normal when the anesthesia was given and no change was indicated until the "moment her infant delivered." At that time a "heart stat" emergency was called, and artificial respiration and other resuscitative efforts were promptly instituted to restore breathing and heart rhythm. Photocopies of the mother's hospital record showed close monitoring of the patient-consistent with the defendant's claim of no malpractice. As the litigation continued, plaintiff's counsel sent out a photocopy service to obtain the baby's chart. The record contained a carbon copy of the delivery room record from the mother's chart. Although these records were duplicates of the originals, comparing the two revealed that significant alterations had been made in the mother's chart. The carbon copy revealed these alterations and demonstrated that the defendants were guilty of malpractice.

Diagnostic Imaging Information

Imaging used to refer only to roentgen films (X-rays), but the digital age has brought about the ability to view and transmit all types of imaging, including both still and real-time images and at a much higher quality of resolution (Figure 26-10). X-rays are still valuable diagnostic tools, and particularly older images can be copied by an X-ray department and maintained for baseline comparisons to be made with more recent films. However, cardiac catheterizations, echocardiography, fetal ultrasound, cerebral angiograms, gastrointestinal studies with contrast, magnetic resonance imaging (MRIs), and many other types of examinations may be stored and copied on digital systems and can be either transmitted electronically to provider practices, providing they have the proper hardware and software to receive and view the studies, or copies can be made and sent by CD or DVD media. (Usually, the CD/DVD will contain sufficient software to run on various types of computer systems.) Patients may hand-carry these copies to the practice from other practices, or the medical assistant might be asked to request a copy from the provider who performed the study. The request should clearly state that the study in its electronic format is being requested rather than simply the dictated report of the study. The office should have a specific area prepared to store this type of media. Place the diagnostic report in the appropriate chart section and clearly note that a digital or film copy of the study has been filed in the corresponding area of the office.

The concept of meaningful use rested on the "5 pillars" of health outcomes policy priorities, namely:

Improving quality, safety, efficiency, and reducing health disparities Engage patients and families in their health Improve care coordination Improve population and public health Ensure adequate privacy and security protection for personal health information

Innocent Party in the Health Record

In the case of the mentally ill patient, health records may contain sensitive and private information regarding the patient's family, friends, employers, and associates. A therapist frequently will record intimate aspects of relatives' and associates' lives. This information may contain falsehoods and inaccuracies based on the patient's delusions and misconceptions. The patient's record may also contain the therapist's assessment of the patient's interaction with family members and other patients. Release of information involving other persons contained in the patient's health record is potentially harmful to all parties involved. Disclosure may damage reputations within the community, affect employment opportunities, cause severe emotional distress, and infringe on the individual privacy of others. If the patient obtains access to the health record and learns about others' opinions, an adverse clinical reaction may occur, and family and social relationships may be severely and permanently disrupted. Information in the health record may be used against persons other than the patient in legal proceedings—for example, divorce, child custody, and competency hearings. At least three courts have held that when family members participate in counseling sessions along with the patient, the health records of the patient may not be disclosed without the consent of the patient and family members. Another potentially troublesome area is the maintenance of confidentiality in group psychotherapy settings.

Meaningful Use

Meaningful use determines the way in which EHR technologies must be implemented and used for a provider to be eligible for the EHR Incentive Programs and to qualify for incentive payments. These incentives specify three components of meaningful use: The use of a certified EHR in a meaningful manner The use of certified EHR technology for electronic exchange of health information to improve quality of health care The use of certified EHR technology to submit clinical quality and other measures The purpose of meaningful use is not only to institute the adoption of EHRs, but to ascertain that practices use their EHR software to its fullest. Benefits of meaningful use include complete and accurate medical records, better access to information, and patient empowerment. One of the major goals of meaningful use is to make medical records interoperable so that immediate access can be given to any provider who works with the patient. The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law on February 17, 2009, by President Obama to promote the adoption and meaningful use of health information technology. HITECH was enacted as part of the American Recovery and Reinvestment Act (ARRA), also known as the "stimulus bill." HITECH provides the Department of Health and Human Services (HHS) with the authority to establish programs to improve health care quality through the promotion of Health Information Technology (HIT).

Living Wills

Most states recognize living wills, although state statutes vary in content for the requirement of a valid "living will." Over the past 30 years, living wills have been accepted by the courts, physicians, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, and lawyers, but only a third of the population has a living will. Living will forms are easy to obtain: contact your state bar association or state department of elder affairs for information appropriate to your state. Efforts to define policies on withholding or withdrawing life-sustaining procedures from hopelessly ill patients are a relatively recent development. All states have living will statutes that vary slightly. These statutes have differing requirements for the contents and authentication of living wills. A living will is a contract, and it must be executed by a competent person. Its intent is to extend the right to refuse artificial life-sustaining procedures into a possible future time of incompetency.

Which of the following is an example of a challenge to the universal adoption of EHR systems?

Not all forms of EHR "talk" to each other.

Soap and Hpip

One of the most frequently used data collection methods for patient visits is the SOAP note or subjective, objective, assessment and plan. SOAP stands for: S—subjective impressions O—objective clinical evidence A—assessment or diagnosis P—plans for further studies, treatment, or management A similar system of recording medical information about patients is the history physical impression plan (HPIP) method: H—history (subjective findings) P—physical exam (objective findings) I—impression (assessment/diagnosis) P—plan (treatment)

Administrative, Financial, and Insurance Information

Prioritize matters in order of importance and complete each task one at a time to help reduce stress and improve efficiency. At the first visit, every patient should be asked to provide the necessary demographic information on the patient data form as completely as possible. This includes such data as full name, Social Security number (SS#), birth date, marital status, address, work and home phone numbers, insurance information, emergency contact information, and so on. Demographic and insurance information should be verified at every visit and any changes updated both on the patient's chart and in the computer. By performing an electronic eligibility check insurance information can be instantly verified. A very important item for a new patient is the HIPAA privacy statement that should be completed with the first encounter and checked for accuracy at every visit. The EHR will have fields to complete to verify the consent, Health Information Exchange (HIE) consent, and Notice of Privacy Practices (NPP) forms have been signed. A sign posted in the reception area and at the checkout window might pose a simple question to patients such as, "Do we have your current address and phone number?" or "Please let us know if there are any changes in your personal information." Some offices post a sign or notice on the back of the exam room door so that a patient can read the reminder while waiting to be seen and let the medical assistant know of any changes. Financial and insurance information should be guarded carefully. This includes insurance policy numbers, credit card information, and any legal documents that might be required when the patient is seen as part of a workers' compensation claim, disability evaluations, or as part of accident or injury evaluations and treatments. It is important for this information to be protected and maintained accurately and clearly to protect the patient's financial well-being as well as to ensure that claims are processed correctly and appropriately. For instance, a patient may be seen by a practice for both regular medical visits that are billed to the patient's private insurance as well as for other instances, when the visit is charged through an attorney for personal injury or workers' compensation as part of a workplace-related injury or illness. Maintaining accurate documentation of each is important to avoid confusion and to be sure that visits are billed correctly.

Privacy and Privileged Communication

Professional confidentiality dates back to the time of Hippocrates: Whatever in connection with my professional practice, or not in connection with it, I see or hear in the life of men, which ought not to be spoken abroad, I will not divulge as recommending that all should be kept secret. Privacy, in the medical setting, involves at least two different kinds of interests. One is individual interest in avoiding disclosure of personal matters; the second is interest in independent decision making. The federal government, in the form of the Health Insurance Portability and Accountability Act (HIPAA), has weighed in on the issue of patient privacy. In this context, the challenge is to maintain that patient privacy in an era in which electronic storage of records has become commonplace. That method of storage makes access to that data easier—and more easily subject to violation.

Progress Notes

Progress notes, as the name implies, document the progress of each patient. Progress notes are entered in the chart chronologically and encompass many types of encounters and communications with the patient, mostly those that occur within the practice but also to record information about the patient from outside the practice. By maintaining a record of visits, prescription refills, all calls that pertain to the patient, and all calls that the patient has had with any member of the health care team, a more comprehensive assessment of the patient's presenting problems can be completed. All interactions that take place between the patient and the medical office should be recorded in the patient's progress notes. Progress notes should be arranged in chronological order, with the most recent date on top and each entry timed, dated, and initialed or signed. If several notes are recorded on a page, the last note on the page should be the most recent. A note is entered for each no-show, cancellation, telephone call, or prescription. The provider or licensed practitioner will likely indicate a preferred format for all notes, which should be adhered to for consistency. One recommended format for progress notes is to label the initial visit for any condition as a specific chief complaint (preferably in the patient's own words) and subsequent visits for the same problem titled as "follow up for (complaint) initially seen on (date)." The chief complaint or presenting problem is a brief description of the reason for the patient's visit. A history of the present illness and any remedies taken by the patient are included with any prescription and over-the-counter (OTC) medications currently used. The patient's medication and drug allergies should be recorded and updated during each subsequent visit. Use abbreviations that are standard and recognizable to the staff and specialty when charting information. Record complaints, as well as any pertinent negatives or signs and symptoms the patient denies, which are also useful pieces of information in making the final diagnosis. Pain levels must be assessed and recorded on the chart by using the standard scale of 1 to 10, with 10 being the worst, or children's pain scales such as Wong-Baker faces or the Oucher! scales. The provider will complete the progress notes by listing all objective findings, assessments, and plans for further treatment and by signing the chart after the patient's examination is completed.

Removal of Life Support

Prolonging life today is often a treatment decision. The physician may make this decision, but it is the nurse who carries out the day-to-day patient care. The withholding of food and water is an indication that the medical community is no longer going to continue nurturing the patient. It is an intentional act. The case involving the removal of the feeding tube from a young woman mentioned earlier in this chapter, Terri Schiavo, became a rallying point for both those supporting the right to die and those supporting the right to life. Over the course of weeks, it led to numerous court actions, legislative action on the state and federal level, direct action by the President of the United States and the Governor of Florida, extensive media coverage, widespread protests, statements from religious leaders, and much more. It underscores the range of opinion and the deep emotional commitments surrounding such issues of life and death. The debate on the removal of feeding tubes shows that there are no easy answers, often just more questions. DNR orders are no longer hidden or camouflaged with purple dots. It has been legally recognized that individuals have the right to make decisions affecting their own death. Procedures are made available to document a dying person's wishes while the person is still considered legally competent. The ethical conflict in these cases is the tension between the obligation to prevent death and the obligation to prevent suffering.

Create and Organize a Patient's Medical Record

Purpose: Prepare an accurate and complete patient chart to submit to the provider for final review. Equipment: Chart or folder, patient records, privacy forms, tabs (if using electronic records: computer and EHR program). Skill: Create a patient's medical record Skill: Organize a patient's medical record Skill: Utilize an electronic medical record Skill: Input patient data utilizing a practice management system Procedure Steps: 1. Prepare chart or folder for patient (electronic or paper). Verify accurate spelling of name. Include demographics, insurance information, privacy forms, and emergency contact information. 2. Retrieve and compile available reports and information. Verify that all records are for the correct patient before including in the record. Misfiled and misidentified records are very difficult to locate later. 3. Sort and organize records by type: operative notes, progress notes from various providers, laboratory reports, radiology, medication flow sheets, immunization records, and so on. (If using electronic records, organize the documents and enter information or scan to correct tab in the EHR.) Organize and tab appropriate sections of the chart. Look for gaps in records where additional information might need to be requested or clarified. Follow the same organizational format for all patients to help avoid omitting important information. 4. Verify accuracy and completeness and submit to provider for final review. Provides an opportunity for any desired information to be requested.

Loss or Concealment of Records

Related to the alteration of health records is the destruction, unavailability, or loss of relevant x-rays, laboratory test results, and other physical evidence. Health records may also be summoned in fraud situations in which a physician claims excessive amounts from insurance companies or welfare agencies, as in the following: Dr. Emanuel Stolman, a diplomate of the Academy of Family Physicians, had practiced for over twenty-five years when he was indicted in 1976 on twenty-three felony counts of illegally receiving state funds from the Medi-Cal program. Dr. Stolman's method of treatment was a folksy sort of approach, and did not match the rigid bookkeeping methods required by the state. The main question was whether or not Dr. Stolman was present in hospitals and nursing homes on the dates he claimed he had examined patients. At issue was whether Dr. Stolman altered his records when he discovered the state was investigating him. Dr. Stolman followed the motto, "Patients, not Paper," and had been writing pulse counts and blood pressure measurements from memory as long as a week later. He stated that he had a good memory, and would write prescriptions for patients from memory within a week's time after a visit. Dr. Stolman's memory became difficult for nurses, ward clerks and medical records clerks to verify during the ten-week trial. The entire medical community went on trial with Dr. Stolman as discrepancies surfaced in records in nursing homes, extended care facilities, hospitals and within the doctor's office.

Delayed Filing of Laboratory Tests

Sixty-seven closed claims with a diagnosis of melanoma were reviewed by the Aetna Life and Casualty Company. Failure to diagnose was the most common allegation in the claims, and the physician's office was the setting most often identified as the site of the alleged malpractice. The study suggested that the flow of medical reports, such as x-ray readings, may be a factor in malpractice suits involving malignancy. In four cases, the physician who ordered an x-ray study did not see the final positive radiology report—the one that probably would have led to earlier diagnosis and treatment. For example: A 78-year-old woman was evaluated by an internist for recurrent indigestion. The radiologist's report suggested the presence of a small soft tissue mass below the left diaphragm, but the patient did not call the physician's office to ask about the result as she had been told to. The physician did not see the results until approximately eight weeks later. An upper G.I. series confirmed the diagnosis. Surgical exploration and biopsy disclosed the unresectable reticulum cell sarcoma of the stomach. The patient died within six weeks. The original report may have been placed in the patient's file during the physician's vacation.

Facsimile (Fax) Transmission of Medical Information

Society is increasingly dependent on the use of the fax to transmit information. However, there are times when a faxed message goes astray, either because of error on the part of the sender or imprecise handling by the receiver. In the health care industry, this may cause a breach in the confidential relationship between physician and patient. Because of the importance of the timely receipt of information about patients in emergency circumstances, a fax may be an appropriate mode for the delivery of medical information. Under other circumstances, either because of the content of the information or the lack of urgency, another method of transferring sensitive information may be more appropriate. A physician should be sure, however, to comply with the Privacy Rules' requirements for disclosures generally. For example, the physician should check whether the "minimum necessary" rule applies and, if it does, limit the information in the fax to the minimum necessary information. Also, a physician should be sure to have appropriate security safeguards in place that are administrative, technical, and physical in nature. For example, the physician should use policies and procedures that require office staff to verify the recipient's fax number and use a cover sheet that does not include protected health information.

There are three stages associated with meaningful use.

Stage 1: Data Capture and Sharing Stage Stage 2: Advance Clinical Processes Stage 3: Improved Outcomes

Ownership of the Health Record

State law determines who owns a patient's health record. In the majority of states, the health care provider owns the health record. In at least one state, the patient owns the health record. And, in several other states, there is no express statute that indicates who owns the health record. Although the physician and others as owners have a property right to the record and can restrict its removal from the premises, the patient's interest in the information is protected by law. Ownership usually carries with it the exclusive right and power to exercise authority and control over the use of the property. In the case of the health record, the owner cannot control the record exclusively. The fact that a hospital or physician owns the piece of paper on which the record is written does not prevent other individuals, professionals, corporations, and courts from claiming a right to see and copy the information. There are competing interests in and claims on the contents of a health record. For example, a physician is ethically obligated to furnish office records to another physician who assumes responsibility for the care of a patient. Ex: A dispute occurred between a physician who was employed by a clinic and the estate of a deceased physician, owner of a medical clinic. Following the death of the owner, the employee removed from the clinic the Daily Reference Book, which disclosed the identity of all the persons treated..., the receipt book which contained a statement of funds, and all current patient records. The estate accused the physician employee of wrongfully removing the records from the clinic. The court held that the employee had wrongfully removed the records from the clinic but the importance of the rights and the interests of the patients who elected to receive [the physician employee's] professional services required that he be allowed to retain such of the health records of these patients as might be found necessary to enable him to render them proper care and treatment. Another example of the physician's inability to absolutely control health records occurs in the disbursement of property at death. Following the death of a physician, the records, which are owned by the physician, cannot be dispensed with or distributed in the same manner as other property. For example: The doctor's will directed his executor to burn and destroy all of his office records and files without opening them. The court held that this was against public policy and ordered the executor to make available records and notes pertaining to patients to succeeding physicians upon authorized request. Consequently, a physician who sought to destroy patient medical records rather than provide patients with an opportunity to transfer their records to new providers would not be acting in accord with the American Medical Association standards: 3.3.1 Management of Medical Records Medical records serve important patient interests for present health care and future needs, as well as insurance, employment, and other purposes. In keeping with the professional responsibility to safeguard the confidentiality of patients' personal information, physicians have an ethical obligation to manage medical records appropriately. This obligation encompasses not only managing the records of current patients, but also retaining old records against possible future need, and providing copies or transferring records to a third party as requested by the patient or the patient's authorized representative when the physician leaves a practice, sells his or her practice, sells his or her practice, retires, or dies. X-rays, magnetic resonance imaging, electrocardiograms, and the results of other diagnostic tests are a form of health record and belong to the physician or the hospital where they are taken. Access to x-rays depends on the policy of the owner. Policy is affected by statutes that may require the owner to give the films to another physician selected by the patient but may not require the owner to give them to a patient for personal viewing. When a physician refers a patient to a radiologist for x-ray studies, the films usually belong to the radiologist and not to the referring physician who receives the radiologist's report.

Subjective and Objective Statements and Information

Subjective I have a headache. I'm feeling palpitations. You don't look well. My baby is fussy. Mrs. Jones has flushed skin and says her mouth feels dry. Objective The patient's temperature is 37.9/100.2 F. Your heart rate is elevated at 120 beats per minute. The patient's skin is pale and diaphoretic, and he is grimacing. The child has not stopped crying for 12 hours and will not take fluids. Mrs. Jones is a diabetic with a sugar of 325 mg/dL by finger-stick testing.

Suicide

Suicide is a disaster for the family, who often experiences guilt and the feeling that "maybe if I had done just a little bit more it would not have happened." Following a suicide, there is nothing more that can be done to help the patient. The attention of professionals turns to the family to help them deal with their loss. There often is anger, speculation about momentary insanity, guilt, and sorrow. Many consider suicide a disgrace to the family, and in many religions suicide is prohibited. Compassion and understanding will do much to help them through a difficult time.

Durable Power of Attorney

The AMA suggests a medical directive as a substitute for the living will and suggests further that these be made available in physicians' offices and hospitals and included as part of the medical record. Assessing the relative merits of the living will and the durable power of attorney for health care, the AMA finds that the durable power of attorney can cover a broader range of illnesses than the living will, which is often linked to situations of terminal illness when death is imminent. In some states, the durable power of attorney may have a different name, such as medical power of attorney. All 50 states recognize some version of the durable power of attorney, having adopted the Uniform Durable Power of Attorney Act or the Uniform Probate Code, or some variation of them. In a durable power of attorney, an individual designates, in writing, another as his or her attorney in fact. The document contains the words "this power of attorney shall not be affected by subsequent disability or incapacity of the principal," "[T]his power of attorney shall become effective upon the disability or incapacity of the principal," or similar words indicating the principal's intent that the authority conferred continues despite disability or incapacity. The authority differs from a regular power of attorney, which terminates upon disability or death. In most cases, the durable power of attorney is accepted for the clauses of instruction contained within the document. If there is no direction to the agent regarding right-to-die issues, the document is interpreted to mean that the agent has no authority on these issues. Occasionally, the agent may be looked to by a hospital or physician to assist in a decision, but as a general rule, without instruction for medical treatment, the document cannot be used for that purpose. Health care durable powers of attorney direct the person appointed to serve as a surrogate in health care decisions under certain circumstances. Some legal practitioners suggest that everyone who has a living will should also execute a durable power of attorney. Again, each state is different in its requirements, and state bar associations have the pertinent information.

Electronic Health Records

The HITECH Act was enacted as part of the American Recovery and Reinvestment Act of 2009 economic stimulus bill. According to the U.S. Department of Health and Human Services, HITECH Act provides the "authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT [information technology], including electronic health records and private and secure electronic health information exchange." Among other changes to the use of information technology in health care, HITECH Act has provided incentives for the "meaningful use" of EHR, and it assesses penalties for noncompliance. Complying with the meaningful use requirement relies on accomplishing specific objectives related to the use of information technology. HITECH proposes the meaningful use of interoperable electronic health records throughout the United States health care delivery system as a critical national goal. Meaningful Use is defined by the use of certified EHR technology in a meaningful manner (for example electronic prescribing); ensuring that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and that in using certified EHR technology the provider must submit to the Secretary of Health & Human Services (HHS) information on quality of care and other measures. Objectives that support a provider's meaningful use of health technology include computerized provider order entry; prescribing prescriptions electronically; providing patients with an electronic copy of their health information; providing clinical summaries for patients for each office visit; recording patient demographics; maintaining an up-to-date problem list of current and active diagnoses; protecting electronic health information; generating lists of patients by specific conditions; sending reminders to patients per patient preference for preventive/follow-up care; providing electronic syndromic surveillance data to public health agencies; recording electronic notes in patient records; identifying and report specific cases to a specialized registry; and providing structured electronic lab results to ambulatory providers, among many others. EHR technology includes both computer hardware and software systems that store patient information. Many times, physicians and hospitals will have similar or identical systems, allowing shared access to the patient's record. Despite the adoption of EHR, there remain several challenges to the universal adoption of EHR systems that can all "talk" to one another. Although there is general agreement that these very expensive systems will help to improve the quality of care, and perhaps the efficiency with which it is provided, the question of "Who pays for it?" looms large. Second, not all forms of EHR "talk" to each other. So the patient who resides in a community and has a physician and hospital that use a particular system may not be able to easily access her record if she becomes ill in another location. Interestingly, this was underscored in the aftermath of Hurricane Katrina. Patients of the Veterans Administration (VA) hospital found that, because the VA has fully integrated all of its patient record keeping, their records could be accessed from anywhere in the United States. While the majority of health care providers have transitioned to EHR, there are still some who have not. Typically, they are (1) smaller practices who have decided the penalty is less daunting than purchasing, installing, and learning an EHR system or (2) physicians who just do not want to integrate computers into the way they practice medicine. Some physicians have even chosen retirement over using EHR. Association of Physicians and Surgeons' President Melinda Woofter, M.D., says, "The number of physicians practicing medicine has been decreasing. The environment to practice medicine has become unbearable and too toxic. Many have chosen early retirement, while others have changed career paths. The number of physicians choosing to opt out of Medicare has been increasing as well."

HIPAA and the Medical Record

The Health Insurance Portability and Accountability Act of 1996, or HIPAA as it is commonly called, required many changes for health providers as well as for health insurance carriers. The areas that pertain primarily to records management include: Maintaining the privacy of health information. Establishing standards for any electronic transmission of health information and related claims. Ensuring the security of all electronic health information. The HIPAA Privacy Rule for all medical data became effective in April 2003 to provide standards for patients' confidential, personal information. Medical facilities realized that they needed to limit what information was released and to whom it was released. All health care providers have specific policies and procedures in place to document the organization's compliance. It is essential for every employee to comply with the policies that apply to any health information released. Most institutions employ a designated HIPAA officer whose responsibility it is to understand the rulings, train the staff in aspects of the ruling, and keep abreast of all changes with respect to HIPAA regulations and recommendations. A designated privacy officer must keep track of who has access to protected health information within a facility. A Security Rule within HIPAA mandates that not only the privacy of medical records but also the security of the records must be guaranteed. The focus of the Security Rule applies to paper records but is primarily concerned with electronic information and methods to protect it from invasion, accidental disclosure, or loss. Within the Security Rule, providers must demonstrate compliance in four core areas: Ensure confidentiality, integrity, and availability of all electronic protected health information (e-PHI) they create, receive, maintain, or transmit. Have policies and procedures in place that identify and protect reasonably anticipated threats to the security or integrity of the information. Have policies and procedures in place to protect against reasonably anticipated, impermissible uses or disclosures. Ensure compliance with the Security Rule in their workforce. In the event of an audit, the Centers for Medicare & Medicaid Services (CMS) will ask for documentation to evaluate how that office is complying with the security standards of the Security Rule (45 CFR § 164.304). Administrative safeguards Physical safeguards Technical safeguards The Department of Health & Human Services (HHS) provides additional guidance papers for assistance with implementation of the security standards on: Organizations, Policies and Procedures, and Documentation Risk Analysis and Risk Management Security Standards: Implementation for the Small Provider Office new-employee orientation and periodic updates should include training in maintaining records security. Understanding the rationales that pertain to health care record security helps ensure that office personnel maintain the requirements necessary for compliance.

Patient Self-Determination Act (PSDA)

The Patient Self-Determination Act, enacted in 1990, requires health care facilities to provide written information to each adult admission regarding patient rights under state law to make decisions involving the acceptance or refusal of medical or surgical treatment. It also requires documentation of the patient's receipt of this information in the medical record as well as whether a patient has executed an advance directive. Institutions cannot condition care on the provision that the patient execute an advance directive or agree to accept treatment. Medical office professionals should know and be able to explain to patients the advance directives options available to them. The PSDA governs all hospitals, nursing homes, rehabilitation facilities, home health agencies, and health maintenance organizations and hospices that receive Medicare/Medicaid payments. Each entity is required to maintain written policies and procedures regarding advance directives and provide information to patients at the time of admission or enrollment. Under the PSDA, the regulated facilities must: provide written information to patients on admission informing them of their rights under state law to executive advance directives; provide written information about to carry out these rights; document whether an advance directive exists for each patient; and educate their staff and community on advance directives.

Subjective vs. Objective Information

The information in the medical record is classified as subjective or objective. The subjective information is supplied by the patient and includes routine information about the patient, past personal and medical history, family history, and chief complaint. The provider and various members of the health care team provide objective information (e.g., vital signs, exam findings, diagnostic tests). The objective information includes examination, laboratory results, special procedure findings, X-ray reports, diagnoses, prescribed treatments, and progress notes.

Parts of the Medical Record

The medical record is divided into the following sections: Patient Information/Demographics Administrative data Financial and insurance information Correspondence Orders/Referrals Past medical records Clinical data Progress notes Diagnostic imaging information Lab information Medications/Allergies Patient paper files are generally arranged in an orderly fashion in sections as follows (with the chart opened flat): progress notes are on the right with physical exam form under them; imaging reports and lab reports are shingled on the inside (right) back cover of the chart; and on the inside cover (left) are immunization records, medication list, and patient data. This is one way to organize a chart. Follow the existing office policy. When filing additional documents in a patient's chart, place them in order of dates with the most current date on top

Attitudes Toward Death and Dying

The questions asked in this chapter are very difficult, and your answers today will be challenged by your experience tomorrow. Death and dying issues question both the sanctity and the quality of life. Nurses, emergency medical technicians, and physicians are confronted with the reality of life-and-death situations, carrying out do-not-resuscitate (DNR) orders and removing life-support systems. All health care employees are affected by their nearness to and interaction with patients. A variety of influences shape our thoughts and feelings about death and dying, including family, religion or spirituality, the media, society, and life experiences. How we each process death and dying depends on how those influences come together to define our own philosophies about the sanctity and quality of life. Physicians, whose first obligation to a patient is to heal, cure, or postpone death for as long as possible, routinely face questions about death and dying. When a cure is not possible, the physician's obligation is to care for and comfort the dying patient.

The Right to Die

The right to die debate continues, as do efforts to legalize such action. A contract to murder is an illegal contract and unenforceable under contract law. Each state has at least one statute that makes killing another person a felony. In some states, it is a crime to attempt to commit suicide, and in others, it is a crime to aid in a suicide. The durable power of attorney, living will, and health care proxies are legal instruments that ensure that personal preferences are known when competence is questioned. The moral implications of euthanasia are still questioned by society.

Types of Health Records

The typical form of the health record has morphed from a collection of handwritten notes and hard copy test results to an electronic file stored on a computer. As with a paper chart, EHR technology is typically tailored toward the health care provider's type of practice. In large outpatient clinics associated with teaching hospitals, the integrated health record is common. With an integrated health record, the patient is represented by a single record that includes all outpatient and inpatient activity. Hospitals, HMOs, or private physicians' offices are completely separate and distinct organizational and legal entities. Cross-indexing of the hospital and outside office records is very limited and usually represented by a copy of the discharge summary from the hospital chart in the office record of the attending physician. The hospital record seldom carries any direct report of medical office visits unless the medical office is part of the hospital. And, even then, the technologies of a hospital and one of its practices may not be compatible. The health record of the nonhospital situation, identified as a record of medical care given in a facility that does not retain the patient overnight, has unique qualities, depending on the specialty of the physicians and the requirements of the state. The more the outpatient facility resembles a hospital, the more the record resembles a hospital record. The medical assistant's care of the health record requires the same attention to detail and confidentiality regardless of whether it is in a hospital setting or a specialist's private office or whether it is a paper chart or an EHR.

Following a physician's death, what should happen to the records of the physician's patients?

They should be made available to the patients' new physicians upon request.

Stage 2: Advance Clinical Processes

This stage focuses on expanding Stage 1 criteria to encourage the use of health information technology (HIT) for continuous quality improvement at the point of care and the exchange of health information in the most structured format possible. To demonstrate meaningful use under Stage 2 criteria, eligible professionals must meet 17 core objectives and 3 menu set objectives that they select from a total list of 6, or a total of 20 core objectives. Some features of Stage 2 include: More rigorous health information exchange (HIE) Increased requirements for e-prescribing and incorporating lab results Electronic transmission of patient care summaries across multiple settings More patient-controlled data

Stage 3: Improved Outcomes

This stage focuses on the following: Promoting improvements in quality, safety, and efficiency Clinical decision support for national high-priority conditions Patient access to self-management tools Improving population health

Stage 1: Data Capture and Sharing Stage

This stage focuses on the following: Electronic capturing of health information in a coded format Using electronically captured health information to track key clinical conditions and communicate information for care coordination purposes. In Stage 2, eligible providers must meet and report on all 17 Stage 1 Core Objectives and meet 3 of 6 Stage 1 Menu objectives. Electronic health records contain reporting featuring both the Core Requirements and Menu Items and allow the provider or practice to generate the reports required. Implementing clinical decision support tools to facilitate disease and medication management Reporting information for quality improvement and public health information

Health Insurance Portability and Accountability Act of 1996

To improve efficiency in transferring information about patients within the health care system, the HIPAA directs Health and Human Services to adopt standard "data elements" and "code sets" for electronic coding throughout the entire health care industry. All providers of health care are required to participate in these provisions. In addition, HIPAA sets standardized guidelines for the protection of a patient's privacy related to health records.

EHR technology includes both computer hardware and software systems that store patient information.

True

Euthanasia means a mercy killing, or actively assisting someone to terminate their life at their request.

True

If a health record has corrections, amendments, modifications, changes, or even misspelled words, it will raise suspicions.

True

Dating, Correcting, and Maintaining the Chart

When documenting the patient's chief complaint or any other information in progress notes, the date and time the note is taken, as well as any dates and times the patient provides regarding the complaint, are important and should be recorded accurately. Indicate a.m. or p.m. when noting the time unless using military time. Whenever a patient is given a prescription or relayed provider advice over the phone, the date and time of the encounter should be recorded. Failed appointments by either cancellation or no-show are noted with date and time as well. In an electronic chart, the EHR software automatically attaches a date and time to each entry. When starting a new page in a paper medical record, record the patient's name and birth date at the top of each page. Anyone who enters notes in the chart must date and sign his or her own entries. In making a correction on handwritten progress notes, the incorrect entry should have a single line drawn through it and the correction written above it or following it and be completed with the time and date. Never use correction fluid or erase the error because it can appear as a fraudulent entry. Begin the note with "correction" or "late entry" when appropriate or indicate the reason for the correction. Write or print neatly and make sure to spell the patient's name correctly. In the case of a difficult name to pronounce, ask the person to provide a phonetic spelling with accent symbols to show the correct pronunciation. When correcting the electronic progress note, you will use the "edit" feature. Charting is part of the permanent medical and legal record. Using black ink makes much better photocopies of the record. When you are finished with a patient's chart, straighten and tidy the forms before filing it, being sure that no pages are hanging over the edge and that papers in the chart are not crumpled. Over time, creases in paper can cause them to rip or become unreadable, damaging the integrity and completeness of the record. After filing additional information in a patient's chart, file it appropriately as soon as possible. Patient charts should be filed when not in use to decrease clutter and minimize the chance of misplacing them. The common practice for transcription is that dictated notes are transcribed as soon as possible following the visit. The transcriptionist prepares the notes and proofreads for errors before printing. However, if an error is found in the progress or chart note at a later time, a single line should be drawn through the error with a correction made, followed by the date, time, and initials of the person making the correction. Each medical specialty has unique terms and phrases that are most frequently used. Most medical offices have software applications that perform spelling checks of anatomical terms, surgical terms, and medications as the text is typed within the program. Spell checker options for word processing packages usually include a feature that enables the user to customize it by adding specific words into the spell checker's dictionary. Many providers also use abbreviations in handwritten notes and dictation specific to their respective specialties. A working knowledge of such words helps identify hard-to-read handwritten entries. However, if in doubt, always ask the author for clarification.

Lab Information

When lab reports arrive in the office, any critical values should be highlighted and noted and the reports presented to the provider for review. If the laboratory technician phoned regarding the results prior to receiving the final copy, a note should be entered in the progress notes along with any action taken at that time. Any preliminary reports with annotations and final initialed lab reports should be placed in chronological order in a separate section of the chart. Some practices prefer to file all laboratory reports in chronological order, whereas others file each type of report together in chronological order. For example, chemistry, complete blood counts (CBCs), and pathology reports are all separated and ordered by groups.

What is substitute judgment?

When one person makes a decision for another

Release of Information

When working in a physician's office, the best rule to follow, unless instructed otherwise, is to refuse to disclose information—even to the point of acknowledging whether the individual is a patient. It is always possible that an enterprising sleuth could figure out the nature of a patient's illness from the specialty of the physician. Six basic principles are suggested for preventing unauthorized disclosure of information: When in doubt, err by not disclosing rather than by disclosing. There are exceptions to this principle, but a mistaken refusal to disclose confidential data is, at least, reversible. Remember that the owner of the privilege to keep information confidential is the patient, not the physician. If the patient is willing to release the data, the physician may not ethically decide to withhold it even "for the patient's own good." Apply the concept of confidentiality equally to all patients despite the physician's assessment of their goals, mores, and lifestyles. A physician cannot ethically inform an insurer of suspicions that a patient is trying to defraud an insurer or that a young man is trying to use a medical excuse to evade the draft. Be familiar with the local statutes including federal, state, and local law plus ordinances, rules, regulations, and administrative decrees of various agencies such as public health departments. When required to divulge a confidence, discuss the situation with the patient. When obligations to society conflict with those of the patient, the physician should discuss the conflict with the patient. When legal guidelines are absent or vague, the criteria of decision are the immediacy and degree of danger to either the patient or society. Get written authorization from the patient before divulging information. To meet standard situations such as requests from third parties, have the patient sign a blanket authorization in advance to release pertinent data to specific third parties. Information should not be released unless the request is specific. The request should have time limits, identify the purposes for which the records will be used, and identify the particular information requested. It is important to check and confirm the credentials of the person and/or organization requesting information from the record. Your office should have a protocol that describes the steps necessary when you have a request for a copy of a health record, and it is highly advisable to follow the protocol.

The Terminally Ill Patient

While advance directives can guide health care for patients unable to make decisions, caring for a terminally ill patient presents ethical issues in addition to those raised by advance directives. What is the purpose of providing care to a patient who has no prospect of recovery? In most cases, the objective is to alleviate suffering and ensure the patient is as comfortable as possible. Often in the last months of life, terminally ill patients will receive hospice care that provides palliative care and supportive services. Palliative care, which is coordinated medical care intended to provide relief from a seriously ill patient's physical or mental discomfort, is the keystone of medical care for terminally ill patients. Hospice care can take place in hospice-dedicated facilities or in patients' homes. Palliative care, including pain management, end of life issues, and emotional support, among others, squarely addresses issues of impending death. In some instances, terminally ill patients are in hospice because they have chosen to forego medical treatment that might extend their lives. In other instances, patients are in hospice because there are no other options. In both cases, most hospice patients find that palliative care allows them to focus on their families, themselves, and other practical issues related to death.

Durable power of attorney

a document allowing the principal (the person writing the durable power of attorney) to delegate to another person the legal authority to act on the principal's behalf.

Hospice

a home or facility where the terminally ill are cared for.

Property right

a right of ownership to a certain thing.

problem-oriented medical record (POMR)

a system of recordkeeping used to collect specific pieces of information regarding a patient during a health care visit, such as patient profile, chief complaint, review of systems, physical examination, laboratory reports, chronic problems, medication and preventive care lists, and patient education.

Living will

a will made by a person in which he or she requests to be allowed to die naturally rather than being kept alive by artificial means in the event there is no probable recovery from mental or physical disability.

Subpoena

a written order to appear at a specified time and place to testify.

Subpoena duces tecum

a written order to produce documents or things.

Cardiopulmonary arrest

cessation of normal functioning of the heart and lungs.

Health care proxy

document appointing one person to act as a surrogate to make health care decisions for another under certain circumstances.

Terminally ill

fatally ill with a condition for which there is no cure.

The PSDA governs all hospitals, nursing homes, rehabilitation facilities, home health agencies, health maintenance organizations, and hospices and requires each entity to:

maintain written policies and procedures regarding advance directives.

Life-sustaining

maintaining or prolonging life in someone not able to do so naturally.

HITECH has provided incentives for the ______________ of electronic health records.

meaningful use

Assisted suicide

one person making it possible for another person to commit suicide.

Purist

one who believes in and follows all traditional rules.

Substitute judgment

one who makes a decision for another.

Premises

physical location, such as an office or building.

Data

pieces of information.

Clear and convincing

that measure of proof that will produce in the mind of the trier of facts a firm belief or conviction as to allegations sought to be established.

You often hear the terms EMR and EHR used interchangeably, but there is a distinction. Electronic health records (EHR) refers to:

the interoperability of electronic medical records, or the ability to share medical records with other health care facilities.

When a physician refers a patient to a radiologist for x-ray studies, the films usually belong to ___________________.

the radiologist

Advance directive

written instructions about a person's future medical care.