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[CLE 115] Medical law & Ethics > Exam 3 Review (Ch. 7,8,9,10) > Flashcards

Exam 3 Review (Ch. 7,8,9,10) Flashcards

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1
Q

Birth

A
  • Physicians must sign certificate of live birth
  • For hospital birth, certificate is filed at county clerk’s office in state birth took place
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2
Q

Death

A
  • Date and time of death
  • Cause of death
  • How long deceased was treated before dying
  • Presence of absence of pregnancy
  • Whether autopsy took place
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3
Q

Death certificate

A
  • 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
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4
Q

Coroner

A
  • Public health officer holds inquest if death from unknown or violent cause
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5
Q

Medical examiner

A
  • Physician (Pathologist) who investigates unexplained deaths and can perform autopsy
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6
Q

Autopsy

A
  • Examination after death to determine cause of death by examining the organs and tissue
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7
Q

Certain deaths require a coroner’s signature:

A
  • 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
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8
Q

Duty to Report AIDS, HIV, and ARC Cases

A
  • 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
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9
Q

Disclosure to Patients of Health Workers’ HIV Status

A
  • 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
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10
Q

Child Abuse Prevention and Treatment Act:

A

Requires reporting of all child abuse cases

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11
Q

Probable cause:

A

A reasonable belief that something improper has happened

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12
Q

Battered child syndrome—

A

Describes a series of injuries, fractures, bruises, and burns. Signs of neglect, malnutrition, poor growth, poor hygiene

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13
Q

Child Abuse

A
  • 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
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14
Q

Elder Abuse

A
  • 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
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15
Q

Spousal Abuse

A
  • 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
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16
Q

Signs of Abuse

A
  • 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
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17
Q

Substance Abuse

A
  • Abuse of prescription drugs is reportable immediately according to law
    • Violation of controlled substances laws is a criminal offense
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18
Q

Food and Drug Administration (FDA):

A

An agency within the Department of Health and Human Services that ultimately oversees and enforces laws regarding drug sales and distribution

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19
Q

Controlled Substances Act of 1970:

A

A federal statute that regulates the manufacture and distribution of drugs that are capable of causing dependency

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20
Q

Medical examiner:

A

A physician, usually a pathologist, who can investigate an unexplained death and perform autopsies

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21
Q

Cultural Considerations

A
  • 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
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22
Q

Stereotyping:

A

Negative generalities concerning specific characteristics about a group are applied to an entire population

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23
Q

Bias:

A

Unfair dislike or preference against someone, can prevent a health care professional from making an impartial judgement

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24
Q

Ethnocentric people:

A

Tend to believe that their way of viewing and experiencing the world is superior to other’s views

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25
Q

Religious Considerations

A
  • 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
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26
Q

Equal Employment Opportunity and Employment Discrimination

A
  • Laws that affect recruitment, placement, pay plans, benefits, penalties, and termination
  • People must be judged primarily by job performance
27
Q

Employment-at-will:

A

The employment takes place at either the will of the employer or the employee

28
Q

Employment-At-Will Concept

A
  • 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
29
Q

Equal Credit Opportunity Act:

A

Prohibits businesses (including hospitals) from denying or granting credit based on race and gender, referred to as discrimination

30
Q

Equal Employment Opportunity Act (EEOA):

A

Authorizes the EEOC to sue employers in federal court on behalf of people whose rights have been violated under Title VII

31
Q

Title VII of the Civil Rights Act of 1964

A
  • 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
32
Q

Affirmative action programs:

A

To remedy discriminating practices in hiring minority group members. Also covered under Title VII

33
Q

Quid pro quo:

A

Something for something (Ex: Sexual favor in exchange for job advancement)

34
Q

Age Discrimination in Employment Act (ADEA):

A
  • 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
35
Q

Age Discrimination in Employment Act (ADEA) of 1967

A
  • Protects persons 40 and older against discrimination
  • Applies to employers with 20 or more employees
  • Mandatory retirement prohibited except for certain exempt executives
36
Q

Americans with Disabilities Act (ADA):

A

Prohibits employers who have more than fifteen employees from discriminating against disabled individuals

37
Q

Americans with Disabilities Act of 2008 (ADAAA):

A

Broadened and clarified the definition of “disability”

38
Q

Americans with Disabilities Act (ADA) of 1990, Amended in 2008

A
  • 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
39
Q

National Labor Relations Act (NLRA):

A

Prohibits employer actions, such as attempting to force employees to stay out of unions, and labels these actions as “unfair labor practices.”

40
Q

National Labor Relations Act (NLRA) of 1935, Amended in 1947

A
  • 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
41
Q

National Labor Relations Act (NLRA) of 1935

A
  • Establishes rights for both employees and employers, and defines some prohibitive acts by employers, called unfair labor practices
  • Also called the Wagner Act
42
Q

Occupational Safety and Health Act (OSHA):

A

Requires an employer to provide a safe and healthy work environment; the employer must protect the worker against hazards

43
Q

Occupational Safety and Health Act (OSHA) of 1970

A
  • 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
44
Q

Health Maintenance Organization (HMO) Act of 1973, Amended in 1996

A
  • 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
45
Q

Consolidated Omnibus Budget Reconciliation Act (COBRA):

A

Offers government financing for health insurance coverage continuation after an employee has been laid off their job

46
Q

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985

A
  • 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
47
Q

Equal Pay Act:

A

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

48
Q

Equal Pay Act of 1963

A
  • Amendment to Fair Labor Standards Act (FLSA)
    • Illegal for employer to discriminate on basis of gender if performing same job
49
Q

Worker’s Compensation Act

A
  • 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
50
Q

Medical record:

A

All the written and computer generated documentation relating to a patient

51
Q

The Medical Record

A
  • 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
52
Q

Purpose of the Medical Record

A
  • 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
53
Q

Contents of the Medical Record

A
  • 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
      • 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
54
Q

Corrections and Alterations

A
  • 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
    • Electronic health record (EHR) corrections
    • Falsification of medical records is grounds for criminal indictment
55
Q

Timeliness of Documentation

A
  • 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
56
Q

Completeness of Entries

A
  • 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”
57
Q

Reporting and Disclosure

A
  • State laws require disclosure of some confidential medical record information without patient’s consent
    • Reporting and disclosure are duties of the physician
58
Q

Use of Medical Record in Court

A
  • 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
59
Q

Electronic medical record (EMR):

A

Fully computerized method of record-keeping

60
Q

HIPAA’s Five Titles

A
  • 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
61
Q

Who is affected by HIPPA

A
  • 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)
62
Q

Protected health information (PHI):

A

Any individually identifiable information that relates to the physical or mental condition or the provision of healthcare to an individual

63
Q

To “deidentify” patient information, remove:

A
  • 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

[CLE 115] Medical law & Ethics (12 decks)

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