Exam 3 Review (Ch. 7,8,9,10) Flashcards
Birth
- Physicians must sign certificate of live birth
- For hospital birth, certificate is filed at county clerk’s office in state birth took place
Death
- Date and time of death
- Cause of death
- How long deceased was treated before dying
- Presence of absence of pregnancy
- Whether autopsy took place
Death certificate
- Usually must be signed within 24 to 72 hours of death
- Proof that a death has occurred
- Often required to confirm information
- Settling an estate
Coroner
- Public health officer holds inquest if death from unknown or violent cause
Medical examiner
- Physician (Pathologist) who investigates unexplained deaths and can perform autopsy
Autopsy
- Examination after death to determine cause of death by examining the organs and tissue
Certain deaths require a coroner’s signature:
- No physician present at time of death
- Violent in nature
- Homicide, suicide, accident
- Death as result of criminal action
- An unlawful death
- Assisted suicide
- Result of undetermined causes
- Caused by electrical, radiation, or chemical injury
- Caused by criminal abortion
- Includes self-induced
- Occurring less than 24 hours after hospital admission
- Of a person who had no physician in attendance within 36 hours of death
- Occurring outside a hospital or licensed health care facility
- Suspicious death
- Fall
- Of a person whose body is not claimed by friend or relative
- Of a person of unknown identity
- Of a child underage of two if death is from unknown cause
- Of a person in jail or prison
Duty to Report AIDS, HIV, and ARC Cases
- All states require reports of these cases to local or state department of health
- Who shall report the case varies from state to state (attending physician, laboratory, etc.)
- Many states have confidentiality statutes
Disclosure to Patients of Health Workers’ HIV Status
- Health care workers consider disclosure an invasion of privacy
- All blood and tissue donors tested
- Patients have desire to know if they are at risk of HIV infection
Child Abuse Prevention and Treatment Act:
Requires reporting of all child abuse cases
Probable cause:
A reasonable belief that something improper has happened
Battered child syndrome—
Describes a series of injuries, fractures, bruises, and burns. Signs of neglect, malnutrition, poor growth, poor hygiene
Child Abuse
- Child Abuse Prevention and Treatment Act: Requires reporting of all child abuse cases
- All abuse must be reported by teachers, health professionals, law enforcement and day care personnel, and social service workers
- Probable cause: A reasonable belief that something improper has happened
- Physicians have been held liable for not reporting cases
- Persons reporting is protected by law from being sued by parents and others
- Battered child syndrome— Describes a series of injuries, fractures, bruises, and burns. Signs of neglect, malnutrition, poor growth, poor hygiene
- Parental neglect
- States generally refrain from involvement
- State may have to intervene when a child is not receiving proper medical care
- All abuse must be reported by teachers, health professionals, law enforcement and day care personnel, and social service workers
Elder Abuse
- Older American Act (1987)
- Includes physical abuse, neglect, exploitation, abandonment, and financial abuse of adults 60 and older
- Protects residents of nursing home facilities
- Protects against financial abuse or exploitation
Spousal Abuse
- Laws governing the reporting vary by state
- Local police may have to become involved when spousal abuse is suspected
- Court may issue restraining or protective order prohibiting abuser from contact with victim
Signs of Abuse
- Repeated injuries
- Bruises and unexplained swelling
- Signs of inadequate nutrition
- Unexplained fractures
- Bite marks
- Unusual marks
- Bruising or swelling in genital area
- Venereal disease and genital abrasions
- Makeup to hide bruises
- Sunglasses worn inside to hide blackened eyes
Substance Abuse
- Abuse of prescription drugs is reportable immediately according to law
- Violation of controlled substances laws is a criminal offense
Food and Drug Administration (FDA):
An agency within the Department of Health and Human Services that ultimately oversees and enforces laws regarding drug sales and distribution
Controlled Substances Act of 1970:
A federal statute that regulates the manufacture and distribution of drugs that are capable of causing dependency
Medical examiner:
A physician, usually a pathologist, who can investigate an unexplained death and perform autopsies
Cultural Considerations
- Background and experience heavily influence personal beliefs
- Stereotyping: Negative generalities concerning specific characteristics about a group are applied to an entire population
- Bias: Unfair dislike or preference against someone, can prevent a health care professional from making an impartial judgement
- Do not judge a person
- Different cultures have their own practices for personal hygiene
- Ethnocentric people: Tend to believe that their way of viewing and experiencing the world is superior to other’s views.
- Communication can be a challenge for many people who do not understand English
- Non-English-speaking patients need brochures and handouts in their own language
- Cultural restrictions can pose difficult situations
Stereotyping:
Negative generalities concerning specific characteristics about a group are applied to an entire population
Bias:
Unfair dislike or preference against someone, can prevent a health care professional from making an impartial judgement
Ethnocentric people:
Tend to believe that their way of viewing and experiencing the world is superior to other’s views
Religious Considerations
- Patient autonomy
- Conditions can result in confusion for the medical professional
- Guardianship may have to be established
- It is never appropriate to judge another person’s customs or beliefs
- Employer has a legal obligation to accommodate religious practices
Equal Employment Opportunity and Employment Discrimination
- Laws that affect recruitment, placement, pay plans, benefits, penalties, and termination
- People must be judged primarily by job performance
Employment-at-will:
The employment takes place at either the will of the employer or the employee
Employment-At-Will Concept
- Employment-at-will: The employment takes place at either the will of the employer or the employee
- Employment takes place at will of either employer or employee
- Employment may be terminated at will at any time for no reason
- Employee may quit at any time
- Exception for a specific employment contract in which employment cannot be terminated during contract period
Equal Credit Opportunity Act:
Prohibits businesses (including hospitals) from denying or granting credit based on race and gender, referred to as discrimination
Equal Employment Opportunity Act (EEOA):
Authorizes the EEOC to sue employers in federal court on behalf of people whose rights have been violated under Title VII
Title VII of the Civil Rights Act of 1964
- Prohibits discrimination, or unfair treatment based on race, color, religion, gender, or national origin
- Forbids discrimination in all aspects of patient care in institutions that receive federal financial assistance
- Makes sexual harassment a form of unlawful sex discrimination
- Equal Employment Opportunity Commission (EEOC)
- Equal Employment Opportunity Commision (EEOC): The group that monitors Title VII of the Civil Rights Act
- Sexual harassment is a form of unlawful sex discrimination
- Quid pro quo: Something for something (Ex: Sexual favor in exchange for job advancement) - Affirmative action programs: To remedy discrimination practices in hiring minority group members. Also covered under Title VII
Affirmative action programs:
To remedy discriminating practices in hiring minority group members. Also covered under Title VII
Quid pro quo:
Something for something (Ex: Sexual favor in exchange for job advancement)
Age Discrimination in Employment Act (ADEA):
- Age Discrimination in Employment Act (ADEA): Protects persons forty years or older against employment discrimination because of age
- Age Discrimination in Employment Act (ADEA) of 1967
- Protects persons 40 and older against discrimination
- Applies to employers with 20 or more employees
- Mandatory retirement prohibited except for certain exempt executives
Age Discrimination in Employment Act (ADEA) of 1967
- Protects persons 40 and older against discrimination
- Applies to employers with 20 or more employees
- Mandatory retirement prohibited except for certain exempt executives
Americans with Disabilities Act (ADA):
Prohibits employers who have more than fifteen employees from discriminating against disabled individuals
Americans with Disabilities Act of 2008 (ADAAA):
Broadened and clarified the definition of “disability”
Americans with Disabilities Act (ADA) of 1990, Amended in 2008
- Prohibits employers who have more than 15 employees from discriminating against individual with disability
- Employer must make reasonable accommodations
- Exception if undue hardship for employer to make accommodations
- AIDS patients protected under this statute
National Labor Relations Act (NLRA):
Prohibits employer actions, such as attempting to force employees to stay out of unions, and labels these actions as “unfair labor practices.”
National Labor Relations Act (NLRA) of 1935, Amended in 1947
- Gives employees right to form and join unions, to bargain collectively, and to strike for better benefits and working conditions
- Purpose of law is to protect employees
National Labor Relations Act (NLRA) of 1935
- Establishes rights for both employees and employers, and defines some prohibitive acts by employers, called unfair labor practices
- Also called the Wagner Act
Occupational Safety and Health Act (OSHA):
Requires an employer to provide a safe and healthy work environment; the employer must protect the worker against hazards
Occupational Safety and Health Act (OSHA) of 1970
- Employer required by law to provide safe and healthy work environment
- Must protect worker against hazards
- Occupational Exposure to Bloodborne Pathogens Standards
- Standards refer to urine, stool, sputum, nasal secretions, vomitus, and sweat if there is visible evidence of blood
Health Maintenance Organization (HMO) Act of 1973, Amended in 1996
- Requires company with 25 or more employees to provide HMO alternative to regular group insurance if HMO is available in area
- Under HMO, patient has limited choice of doctors
- Patient may have to get a second opinion and permission from HMO for major procedures
Consolidated Omnibus Budget Reconciliation Act (COBRA):
Offers government financing for health insurance coverage continuation after an employee has been laid off their job
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985
- Company with 25 or more employees must provide extended health care insurance to terminated employees for as long as 18 months
- Usually at employee’s expense
Equal Pay Act:
Makes it illegal for an employer to discriminate on the basis of gender in payment to men and woman who are performing the same job
Equal Pay Act of 1963
- Amendment to Fair Labor Standards Act (FLSA)
- Illegal for employer to discriminate on basis of gender if performing same job
Worker’s Compensation Act
- Protects workers and families from financial problems resulting from employment-related injury, disease, or death
- Employers pay into a fund to help cover costs when employee has work-related injury or disease
- Goal to get employee back to work as soon as possible
Medical record:
All the written and computer generated documentation relating to a patient
The Medical Record
- Also called the health record
- All written documentation relating to patient, including:
- Past history
- Current diagnosis and treatment
- Correspondence relating to patient
- A legal document
- May be subpoenaed
- All written documentation relating to patient, including:
Purpose of the Medical Record
- Record of patient from birth to death
- Document for continual management of patient’s health
care - Provides data and statistics
- Tracks ongoing patterns of patient’s health
- Document for continual management of patient’s health
Contents of the Medical Record
- Personal information about patient
- Clinical data or information
- Records of medical examinations
- X-rays
- Lab reports
- Consent forms
- Referrals: PT/OT
- Prescriptions and refills
- Admitting diagnosis
- Evidence of a physician examination
- Not more than seven days before admission or 48
hours after admission to a hospital
- Not more than seven days before admission or 48
- Documentation of any complications
- Signed consent forms
- Consultation reports
- Physicians’ and health care professionals’ notes
- Discharge summary, with follow-up care
- Should never contain irrelevant material
- Clinical data or information
Corrections and Alterations
- Errors require correction
- Nothing should be deleted
- Note in the margin of the record why the change was
made - Use black or blue ink
- Draw one line through error
- Write correction above error
- Date and initial change
- Do not erase or use correction fluid
- Note in the margin of the record why the change was
- Electronic health record (EHR) corrections
- Falsification of medical records is grounds for criminal indictment
- Nothing should be deleted
Timeliness of Documentation
- Medical records must be accurate and timely
- All entries must be made as care occurs or as soon as
possible afterward - Should be completed by physician within 30 days following patient’s discharge from hospital
- All entries must be made as care occurs or as soon as
Completeness of Entries
- Medical records document type and amount of patient care that was given
- In eyes of court, “if it’s not documented, it wasn’t done”
Reporting and Disclosure
- State laws require disclosure of some confidential medical record information without patient’s consent
- Reporting and disclosure are duties of the physician
Use of Medical Record in Court
- Improper Disclosure
- Health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization- Subpoena Duces Tecum
- Written order requiring person to appear in court, give testimony, and bring information described in subpoena
- Subpoena Duces Tecum
Electronic medical record (EMR):
Fully computerized method of record-keeping
HIPAA’s Five Titles
- Title I: Protects health insurance coverage for workers and their families when they change or lose their jobs
- Title II: Known as the Administrative Simplification provisions
- Requires national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers
- Title III: Sets guidelines for pre-tax medical spending accounts
- Title IV: Sets guidelines for group health plans
- Title V: Governs company-owned life insurance policies
- Title II: Known as the Administrative Simplification provisions
Who is affected by HIPPA
- Public health authorities
- Health care clearinghouses
- Self-insured employers
- Private insurers
- Information systems vendors
- Various service organizations
- Universities
- Health care plans
- Treatment, payment, and health care operations (TPO)
Protected health information (PHI):
Any individually identifiable information that relates to the physical or mental condition or the provision of healthcare to an individual
To “deidentify” patient information, remove:
- Patient’s name
- Address, including e-mail
- Telephone and fax numbers
- All dates, including birth (except year), admission, discharge, and death
- Social security number
- Medical records numbers
- Health care insurance numbers
- License numbers
- Facial photos
- Other identifying numbers or characteristics
- E-mail and website address
- Motor vehicle registration numbers
- Facial photographs, such as found on driver’s license
