chapter 4 Flashcards
Subpoena duces Tecum
“bring with you under penalty of punishment” a requirement that documents be delivered to a court or brought with you to court
insurance
the transfer of an obligation from one party to another, usually in exchange for a fee
actuarial tables
a comprehensive list of statistical data
upcoding
using an incorrect international classification of diseases (ICD) or current procedure terminology (CPT) code to gain a larger insurance payment
respondeat superior
“let the master answer” the employer is responsible for its employees
vicarious liability
liability w/o fault. being held accountable for ones action even though you committed no wrong
contract
an agreement between parties that the law will recognize
reasonable person standard
a legal standard used to determine whether the actions of a party are warranted
medical records used to
manage healthcare track healthcare provide clinical data meet regulatory requirements document healthcare
managing healthcare
reviewing patients medical history
- past diseases
- past treatments
- past response to care
tracking care
why a patient sought medical care where a patient received care what medical care was provided when the patient received care hoe the patient responded to care
providing clinical data
research
statistical information
public health officials
regulatory requirements
Joint Commision in Accreditation of Healthcare Organizations (JCAHO)
- Evaluates records
- determines compliance with standards
- required for Medicare/Medicaid
documenting
what to write
- medical approach
- legal approach
medical approach
pertinent information
who, what, where, when, and how
review the purposes of medical records serve
legal approach
legal document possible use in lawsuits and trial used to demonstrate what care was provided used to refresh your memory what is NOT written subpoena ducus tecum
medical record ownership
dually owned by both the patient and the healthcare institution
- institution: paper
- patients: information
- Doctrine of professional discretion: allows a physician to decide whether to release a patients medical records or not
- hypochondriacs: a patients who have a preoccupation with disease and illness
- psychological/psychiatric records: with holding information for the safety of the patient
storage and retention
statue of limitations
legal maxim
20 years from last date of service
insurance
written for anything
car insurance example
actuarial tables
premiums
managed care
skyrocketing healthcare costs economize healthcare spending ICD codes: inpatient CPT codes: outpatient upcoding
legal document
any writing that provides information or ideasthat can be attributed to the author
malpractice insurance
all healthcare providers
employment provided malpractice insurance
respondeat superior
vicarious liability
elements required for contracts
offer: though of as a desire to enter an agreement
acceptance: the taking of the offer, does not require a verbal response
consideration: whether the parties have thought about what they are giving up when entering into a contract
- contractual capacity
- implied contracts
- reasonable person standard
statue of fraud
a law that indicates when a contract must be in writing in order for the courts to recognize that contract
- executors/administrator agreements
- Employement contracts
- interest in land
- the sale of any item $7,500 or more
