Ethics for Health Professional: Chapter 6 Accountability: The Medical Record

Consistency and content are a great signifigance

(refer to phone of image of content in a medical record )

The medical record is...

-A written story of a patient's medical history -It enables the physician to do the following: (See image in phone) It makes it possible for the healthcare professional to provide the most appropriate patient services

Name all 4 ethical principles of the EMR

1. Autonomy 2. Trust 3. Justice 4. Fidelity

2 Types of medical record charting are

1. The Narrative Method 2. The SOAP Method

What is a hopper?

A patient who switches from doctor to doctor Sometimes patients go from doctor to doctor because they cannot find the satisfaction that that are looking for in a healthcare provider Sometimes it may be because they owe money Other times its because they are seeking medications (pain medication) Advocates of a nationally standardized electronic medical records system content that electronic records would virtually do away with a hopper

What are a controverisla issue in charting?

Abbreviations There are so many abbreviations that some could be confused This is why professional organizations, educational institutions, and government agencies often have their own lists of approved abbreviations. The facility where you work should have an approved list on file and could even post some near work stations as reminders

Why is the medical record considered a legal document?

Because the information in the record is often used as a primary source of evidence in lawsuits Remember this is your everyday documentation practices becuase what you provide in writing could win or lose a legal case if you are ever subpoenaed to be part of a case, you may have to defend what and how you have recorded information in a medical record You may later remember something that you did not include, but you will not be able to use that information once a subpoena has been issued

The purpose of confidentiality is to protect the patient reflecting upon this, you can rationalize that to further protect some patients, there are sometimes reasons why it is not good for the patient to have access to his or her own medical record

Ex. The patient might do himself or herself harm , or the patient might be in an at risk group: -Children -Elderly patients-who might not be capable of making sound decisions -Mental health patients

Every institution or office must have a medical record that possesses the following characteristics with the mnemonic FLOAT

FLOAT: -Factual -Legible -Objective -Accurate -Timely

Trust is

If a patient fears that the EMR might fall into the wrong hands, that patients might be less likely to fully disclose health information ex. pain level and disability

What color should medical entries be done in?

In BLUE or BLACK physcians are now oftern choosing preprinted forms to save time and improve legitibality issues But physcians must still provide the time and date, and authenticate the information Authentication may include,,written signatures, initials, computer key, or other code

Legible means

In a lawsuit, a physicians handwriting must be legible and they must do what they can to improve it if it is not.

What is the narrative charting method?

It consist of thorough but concise documentation Although it may seems like the easiest method, this method can make it difficult to decipher patient information and to fit all the information together to make decisions about patient care Progress notes often are a part of this method

What is timeliness?

It is the essence of medical accountability When you are with a patient, you should be making notes immediately to ensure the most accurate information To do anything else is a disservice to the patient and this reflects on your professionalism

What is the soap method?

It often produces a more consistent record SOAP is a mnemonic for Subjective- The patient's chief complaints Objective- The healthcare professional's observation and findings through examination and conversation Assessment- Conclusions based on the subjective and objective information Plan of Action- The treatment that is advised based on the conclusions By using this method, entries are easy to track thoughout the record byb category and, therefore may even save time for teh phsicain(s) reviewing it

Factual means:

Since the medical record is a legal document, it is essential that it be factual If brought into a legal case, it will be reviewed and possibly presented as evidence The judge or jury will not be able to come to a conclusion on a point if it is not in the record The phrase: "Not recorded...did not happen " will be enforced Also if you are about to perform a procedure , such as an injection, do not record until after you have completed the procedure

What is TJC? What is its mission?

The Joint Commission (TJC), A not-for-profit agency established in 1951, is an accreditation agency in the United States that reviews patient documentation Its mission is "to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value" (TJC 2012) The agency DOES NOT review only the records of hospitals TJC also evaluates other patient services facilities such as dental offices, nursing homes, clinics, surgery facilities, and urgent care facilities To earn and maintain TJC's "Gold Seal of Approval, an organization must undergo an on-site survey by Joint Commission survey team at least 3 years" Laboratories must be surveyed every 2 years If a TJC representative visists your place of employment, rmeebr that he or she is just there to help suggest improvements according to Gold Seal of Approval standards Your best strategy is to cooperate fully The repreentaitive will complete a written report on the audit ], and your faculty will be given time to make corrections An audit can be a valuable learning experience so should your employer be audited, take the opportunity to learn from the experience and pay attention to the kinds of information that they are gathering, if able

What is the electronic medical record (EMR)?

The electronic medical record is a medical record documented on and available by computer. It is also refereed to as an EHR (electronic health record) The issue of digitizing medical records has become controversy Concerns are the EMR would include vulnerability to hackers and that any altered records could jeopardize the health , and possibly the very life, of the patient. Critics of the EMR system maintian, if the computer systems of the US Pentagon can be kacked into, then surely an EMR system could fall prey to intruders Supports of EMR argue electronic systems allow for more efficient collaboration between physicians and that the systems are quicker to access than having to request and wait to receive written records The issue of legibility discussed in this chapter would become a non factor, though spelling mistakes would remain a problem

Accurate

The medical record is only accurate as the efforts of those who record in it The lack of accuracy , after all, can be the difference between a patient experience improves health and one experiencing a life-threatening situation Spelling and grammar are also crucial. Accuracy does not refer just to information One should always double check to assure that you have the correct medical record before beginning to document -a simple, yet costly mistake

Objective means

The word objective suggests impartiality and fairness It makes sense that the information contained in the medical record be objective Personal opinions have no place in the medical record Terms such as "disagreeable" are subjective and should not be used nor do they belong in the record, terms such as "every" or "never" are rarely true If the record is clogged with personal comments and unnecessary information, it could hinder the assessments made in offering patient care Always document as if you were trying to explain something very important to someone else: Be concise, but do not leave out any relevant details

Every patient has the right to have the details of his or her medical information protected , as specified by the Health Insurance Portability and Accountanbility Act (HIPPA)

There are some exceptions , but for the most part the patient decides who gets to see his or her personal medical information For the Frank Smith case study, he has the right to have details of his illness kept private The only case where it must be disclose if it was the case of whooping cough or another contagious condition listed by the Center of Disease Control and Prevention (CDC) as shareable Frank is not legally bound to report his virus to his employer but he may feel it is ethically appropriate to report his contagious condition

What is the prefered delivery method?

Through registered mail or through a reliable delivery service where a signature is required fax is a common way of sending medical information, but itshould be used with great care It, like email, should not be used only when the information is needed immediately and/or when other communication avenues are not feasible, and it should be used only with proper documentation of permission Some states have laws that prohibit the faxing of medical information Additionally, sending medical information by email is quite risky, as unauthorized persons may be able to view it See image in phone for tips for faxing medical information

T or F Whether you do or do not support the EMR system, they are now required for all healthcare facilities.

True The U.S. federal government mandated every medical facility to provide evidence of ""meaningful use" of an EMR system , as prescribed by the state of location, by the year 2015

Justice is

Would all people have equal access to EMRs, including those of lower socioeconomic status and those who do not speak English?

Autonomy is

a person's ability to make decisions concerning his or her own personal well-being, including health care

According to the American Health Information Management Association.....

if you are not able to enter the information in a timely manner (meaning soon after the service was provided to the patient), you may add a late entry or addendum, if it is clearly marked as such Do not confuse a late entry with an addendum, either which is permitted, with information added unethically to enhance a medical record in preparation for court use Unethical practices of adding information can result in punishment to the person making the entry (American Health Information Management Association, n.d)

Fidelity is

in the field of ethics simply means loyalty

What is a subpoena duces tecum?

it is Latin for "bring with you under penalty of punishment"

When you make a mistake with charting....

when you make a mistake in a traditional medical record, you should never use correction fluid or erase the entry in any way Instead, draw a thin line (also called strikethrough) through the mistake and write your initials and the date above the line In doing so, the former statement can be seen in case there is any discrepancy Corrections on the electronic medical record will be dependent on the type of system utilized by your employer