clinic manual Flashcards
what are the general responsibilities of the observer?
- clean the treatment room before & after each treatment
- supply treatment rooms with suppies like moxa, alcohol, paper gowns, table paper, cotton swabs, cotton balls, linaments
- provide support for the treatment process
- provide support for the clinic process through filling herbal formulas (with supervision)
what are the observer’s goals with respect to patient care?
- observe all phases of clinical care & participate under the guidance of the intern & supervisor
- exhibit caring, compassionate, and respectful behaviors in patient care
what are the observer’s goals with respect to medical knowledge?
show basic understanding of the 4 examinations, acupuncture point & herb functions, and their application to patients
what are the observer’s goals with respect to practice-based learning & improvement?
assess own performance in the clinic for needed improvements, and implement those improvements using appropriate information literacy skills
what are the observer’s goals with respect to interpersonal & communication skills?
demonstrate good communication skills with clinic faculty, staff, patients, and other students
what are the observer’s goals with respect to professionalism?
demonstrate familiarity with clinic policies, procedures, and paperwork
what are the observer’s goals with respect to systems-based practice
demonstrate basic knowledge of practice & delivery systems
what are some other requirements concurrent with observation in the clinic?
- complete prerequisite courses
- complete of clinic orientation
- complete HIPAA training
- complete “clinic observer orientation check list” by week 3
- obtain a current 8-hour adult & child CPR and first aid card
- document hepatitis B vaccination or sign waiver
what is an informed consent form?
- for new patients, it must be signed by both patient & practitioner prior to the start of treatment
- it clarifies that the practitioner has explained the nature of treatment, the risks of treatment, alternatives to treatment, benefits of treatment, etc
what is an arbitration form?
it clarifies that in the case of a dispute, the dispute will be settled via arbitration (as opposed to in court)
what is HIPAA?
- stands for “Health Insurance Portability & Accountability Act”
- describes in detail the patient’s rights and the clinic and practitioner’s responsibilities with respect to HIPAA and private health information
what are some rules regarding the privacy of a patient’s case or treatment?
- never discuss cases in public areas
- never use patient names or identifying info
- never disclose that a patient is visiting the clinic (other than to your supervisors and/or assistants)
- never share any details about the patient’s condition to clinic staff members
if a patient approaches you at a coffee shop, can you mention their case or treatment?
no, unless the patient voluntarily brings it up first
can patient charts be removed from the building?
no, they cannot be removed from the building (and they really should not be removed from the clinic floor)
can patient charts be photocopied?
no, unless:
- for educational purposes and with proper obscuring of any identifying info
- under subpoena
- under express written consent of patient
what must be done when photocopying patient charts?
obscure any identifying information by covering it with opaque material prior to photocopying
under what circumstances are PCOM students and supervisors allowed to clinical information?
- to communicate with other health care providers using the same chart to treat a patient
- as a reference for treatment of future illnesses
- as a training tool for student trainees
- to evaluate the quality of patient care through review & analysis
- as a research tool for both educational & treatment development purposes
- for documentation to conform to government regulations
- for follow-up care of patients with long-term illnesses and assessment of efficiency of care given
under what circumstances are clinical students allowed to handle patient charts?
- to perform patient intake
- to prepare herbal prescriptions
- to obtain information for educational purposes (need to complete the “chart file request form,” and this can only be done if the intern has been actively involved in the patient’s care)
what kind of pen or pencil must be used on medical charts
black ink only (no other color is acceptable; no pencils)
T or F: nothing must be left blank on the chart
true (if you don’t have specific data, write NA or explain why)
what is the proper way to make a correction on the chart?
- draw ONLY ONE LINE through the error
- then write your initials and the date of the correction
T or F: all interactions with patient, including phone & email conversations, must be charted
true - need to fill out the “chart continuation form”
as a practitioner, what is the best way to avoid misunderstanding about sexual misconduct?
ask for permission and receive verbal consent before touching near or on any sensitive areas like the lower abdomen, genitals, breasts, or buttocks
T or F: observing Universal Precautions means that all needles are assumed to be potential sources of exposure to any known or blood-borne pathogens such as HIV and Hepatitis B or C
true
