federal medical laws Flashcards
HIPAA
health insurance portability and accountability act
what are the key components of HIPAA guidelines?
- privacy rule: protects patients’ medical records and personal health information (PHI)
- requires providers to explain patient rights + written/implied consent
- covered entities must follow HIPAA (+ business associates)
when is authorization for PHI not required?
- someone in risk of spreading communicable disease
- victims of abuse/neglect
- health oversight agencies
- judicial/admin proceedings
- law enforcement purpose
- workers’ compensation
components of medical record
- patient identification (name/DOB/gender/identifiers)
- medical history
- diagnosis + treatment plans
- progress notes (SOAP)
- test results
- correspondence (between healthcare professsionals)
SOAP
- subjective
- objective
- assessment
- plan
HITECH act of 2009
- health information technology for economic and clinical health
- improves efficiency/quality of EHR
- barriers to info exchange
malfeasance
an unlawful/wrongful act (ex. performing procedure on wrong patient)
misfeasance
performing lawful action illegally/improperly (ex. performing on correct pt but doing so incorrectly)
negligence
failure to do something a reasonable person would do in a certain situation
nonfeasance
failure to perform task/duty that one agreed to perform or has legal duty to perform (ex. not treating until too late)
affordable care act (ACA)
- provides americans with affordable/quality health insurance
occupational safety and health administration (OSHA)
- employers are accountable for providing safe workplaces for employees
- sets standards for training/outreach/education/assistance
controlled substances act (CSA)
- federal policy regulating manufacturing/distribution of controlled substances
- classifies medications into 5 schedules
title VII of civil rights act
- prohibits employees w/ 15+ employees from discriminating on basis of race/origin/gender/religion
equal pay act
- mandates same pay for all people who do substantially equal work regardless of sex
americans with disabilities act (ADA)
- forbids discrimination against anyone who can perform a job regardless of disability
- requires accommodations
family leave act (FMLA)
- certain employers must give time off to employees for familial/medical reasons
the joint commission (TJC)
- improve risk management
- strengthen patient safety + quality of care
- provide framework for organizational structure/management
who owns a patient’s medical record?
the medical facility the patient is treated at
TJC’s do not use abbreviations
- unit
- international unit (IU)
- daily (qd)
- every other day (qod)
- trailing/lack of trailing zero
- MS (morphine sulfate + magnesium sulfate)
21st century cures act
helps provide tools/resources to advance medical research + innovation
dereliction
negligence/deviation from standard of care
how to obtain consent from minors
only informed consent can be obtained from a legal guardian/parent on minor patient’s behalf
how to obtain consent from those unable to give consent
- obtain consent from a legally authorized representative (ex. family member/guardian/POA)
- emergency situations = initiate treatment w/o consent (act in their best interest)
patient’s bill of rights (PBR)
- right to access care
- right to receive respect
- right to be free from discrimination based on race/age/disability/etc.
- right to receive clear info on diagnosis/treatment
- right to participate in their care decisions
- right to appeal claim denials (grievance process)
