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