Chapter 2: Legal and Ethical Responsibilities

What 6 aspects does the healthcare code of ethics include?

1. Autonomy 2. Fidelity 3. Beneficence 4. Nonmaleficence 5. Veracity 6. Confidentiality

What are the 3 types of abuse?

1. emotional 2. physical 3. sexual

What are the 3 levels of liability in healthcare?

1. personal liability 2. supervisory liability 3. employer liability

When using electronic medical records, what are the 3 types of safeguards health care facilities must provide according to the Security Rule?

1. physical safeguards; locked doors 2. technical safeguards; passwords 3. administrative safeguards; restricted access

What are 6 patient rights under the Privacy Rule?

1. the right to an accounting of disclosures; enables patients to learn to whom the covered entity has disclosed their personal health information and will cover up to six years prior to the individual's request date 2. the right to access a minor child's medical records 3. the right to notice of privacy policy; the patient must be given a written copy of patient's rights regarding protected health information 4. the right to request amendment of personal health information 5. the right to confidential communications; patients may request reasonable, alternative forms of communication. 6. the right to complain of privacy violations 7. the right to access a copy of the patient's medical record 8. the right to make specific privacy requests

Release of Information (ROI)

process of disclosing patient-identifiable information from the health record to another party; a form signed by a patient or health care facility that allows for copying and releasing of patient information

Health Insurance Access, Portability, and Renewability Rule (HIPAA)

provides continuous insurance coverage for people when they change or lose a job; prevents health insurance companies from denying or limiting coverage for people who have pre-existing conditions

Security Rule (HIPAA)

provides regulations to make sure that confidential patient health records are kept secure

Which section of the patient record is legally allowed to be kept from the patient?

psychotherapy notes; mental health notes

Competence

qualified and capable of performing a task

Authorization

the permission that patients give in order to disclose protected health information. Several elements must be included in formal authorization

Ethics

the principles of right and wrong that guide an individual in making decisions

Deposition

the process of attorneys questioning witnesses during a court hearing

Value Clarification

the process of self-evaluation that helps gain insight into personal values

Dependability

the quality of being trustworthy and reliable

Disclosure

the release, transfer, or provision of access to protected health information; patients must give permission for their health information to be disclosed to other people

Civil Law

the system of law concerned with individual rights and private relations between members of a community

The Privacy Rule (HIPAA)

established nationwide standards that are used to protect private patient information

Emotional Abuse

excessive demands, insults, humiliation, jealousy, control, isolation, stalking, threats, lack of affection, and lack of support

Civil Litigation

lawsuit in a civil court, it begins when the plaintiff contacts an attorney

Standards of Care

legal requirements for nursing practice that describe minimum acceptable nursing care

True or False? When health data is needed for research, the entire medical record is disclosed to the researchers?

false; when information is needed for public health research identifying information has been removed from the data

What are six situations for when disclosure of protected health information is allowed without authorization?

1. when a patient requests to see their own medical information 2. when permission to disclose is obtained 3. when information is used for treatment, payment, or healthcare operations 4. when disclosures are obtained incidentally; obtained accidentally, even when privacy precautions are taken 5. when information is needed for public health research; in these cases identifying information has been removed from the data 6. when there are legal or public interest issues are involved

HIPAA

Health Insurance Portability and Accountability Act of 1996

Ethical Dilemma

a decision that involves a conflict of values; every potential course of action has some significant negative consequences; there is no clear right or wrong answer

Summons

a document informing a defendant that a legal action has been commenced against him or her and that the defendant must appear in court on a certain date to answer the plaintiff's complaint (The document is delivered by a sheriff or any other person so authorized)

Living Will

a document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes

Durable Power of Attorney (POA)

a document that permits an individual to appoint another person to make any decisions regarding health care if the principal should become unable to make decisions

Criminal Law

a law that defines crimes against society; includes public offenses

Advanced Directives

a legal document designed to indicate a person's wishes regarding care in case of a terminal illness or during the dying process; there are two types of advanced directives living wills and durable power of attorney

Libel

a written defamation of a person's character, reputation, business, or property rights

Mandated Reporter

an individual who holds a professional position that requires him/her to report to the appropriate state agency cases of abuse that he or she has reasonable cause to suspect

Defendant

an individual, company, or institution sued or accused in a court of law

Assault

an intentional threat, show of force, movement that causes a reasonable fear of, or an actual physical contact with, another person

Abuse

any action or failure to act which causes unreasonable suffering, misery, or harm to the patient; includes physically striking or sexually assaulting a patient, intentional withholding of necessary food, physical care, and/or medical interventions

Protected Health Information (PHI)

any individually identifiable health information about a patient; information about a patient's health status, provision of health care, payment for health care, patient's name, social security number, address, telephone number, date of birth etc

When are medical facilities required to notify patients of the privacy policy?

at the patient's first visit to the facility

Nonmaleficence

avoidance of harm or hurt; do no harm

Liability

being legally responsible

What type of abuse includes excessive demands, insults, humiliation, jealousy, control, isolation, stalking, threats, lack of affection, and lack of support?

emotional abuse

Fidelity

caring for patients according to the profession's scope of practice

Discretion

cautious reserve in speech; ability to make responsible decisions

Veracity

communicating with truthfulness, honesty, and accuracy

Privileged Communication

confidential information that has been told to a physician (or attorney) by the patient

DNR order

do not resuscitate order; prohibits resuscitation attempts

Beneficence

doing good or causing good to be done; promoting patient health and well being

Who do medical records belong to?

health care providers

Integrity

honesty, high moral standards; a willingness to admit mistakes so they can be corrected

Physical Abuse

includes hitting, kicking, pushing, shaking, pulling hair, pinching, choking, biting, burning, scalding, threatening with a weapon, inappropriate restraint., withholding food and water, not providing physical care, and abandonment

Sexual Abuse

includes using sexual gestures, suggesting sexual behavior, and unwanted sexual touching or acts

Risk Management

is a process of identifying, evaluating, and preventing sources of liability

Transaction and Code Set Rule (HIPAA)

national standards for health transactions; as a result of this rule all medical transactions and codes have become the same nationwide

Malpractice

negligence by a professional person; failure to provide care that results in harm to the patient

Sanction

official permission or approval; document that outlines acceptable behavior

Plaintiff

one who brings a court action against another

Advocate

one who defends or pleas a cause or issue on behalf of another

Autonomy

respecting patients' right to make decisions regarding their health care

Confidentiality

the act of holding information in confidence, not to be released to unauthorized individuals; using discretion when handling protected health information

Euthanasia

the act of letting a person die; withholding lifesaving interventions

Slander

the action or crime of making a false spoken statement damaging to a person's reputation

Negligence

the commission or omission of an act that a reasonably prudent person would perform in a similar situation

Verdict

the decision a judge or jury makes in a trial

Values

the ideas, beliefs, and attitudes about what is important; personal beliefs about the value of an object

Informed Consent

the legal basis for informed consent, usually outlined in a state's medical practice acts

Tort

type of civil law that involves wrongs against a person or property; torts include negligence, assault, false imprisonment, fraud, defamation, and invasion of privacy

False imprisonment

unauthorized restraint or detention of a person

Battery

unlawful touching of another person without consent

Invasion of Privacy

unwelcome and unlawful intrusion into one's private life so as to cause outrage, mental suffering, or humiliation; a violation in a patient's legal rights to privacy

Accountability

willingness to take credit and blame for actions