Laws & Records Flashcards
1
Q
INFORMED CONSENT
A
- must be signed
- must show procedure was consented to
- must address nature of procedure, alternatives, risks involved & probable consequences, and demonstrate patient understood concerns
- patient must fill in date of signing
Particularly important when using techniques that might be interpreted as causing damage to body, such as direct moxibustion & cupping or gua sha which may leave bruises
2
Q
RECORD KEEPING
(H.B. KIM)
A
- maintain accurate patient records
- acupuncture must follow standard medical charting procedures such as SOAP notes
- daily treatment records should include points & treatment procedures for each visit
- if changes are made in record during treatment, draw a line through text in question & initial change & then record updated information
- DO NOT scratch out or render illegible any information recorded in chart note
- all medical records are to be kept for 7 years
- records of daily appointments schedules must be retained
- Practitioners may not release information regarding a patient, either verbally or in writing without the patient’s consent
- practitioners may discuss cases w/ other health care professionals so long as there is no identifying information
3
Q
CHILD ABUSE
A
- any practitioner who has knowledge of, or observes, a child in his or her professional capacity or within scope of his or her employment whom he or she knows or reasonably suspects has been victim of child abuse or neglect to report known or suspected instance of child abuse or neglect immediately, or as soon as practically possible, by telephone** & to prepare & send a **written report** thereof **within 36 hours of receiving informatin concerning incident
- a report of suspected child abuse or neglect** must be made to **police department or sheriff’s department, not including a school district police or security department, county probation department (if it has been designated by county to receive mandated reports), or country welfare department
- “Child abuse or neglect” includes a physical injury inflicted by other than accidental menas upon a child by another person, sexual abuse, neglect, willful cruelty or unjustifiable punishment, & unlawful corporal punishment or injury. It includes child abuse or neglect in out-of-home care
- any mandatory reporter who has knowledge of or reasonably suspects that unjustifiable mental suffering has been inflicted upon a child or that his or her emotional well being is endangered in any other way may make a report
- failure to comply w/ the requirements of Penal Code section 11166 is a misdemeanor, punishable by up to six months** in a county jail, by a fine of **$1,000, or by both the imprisonment and the fine
4
Q
ELDERLY ABUSE
A
- practitioner’s are required to report elderly abuse** if they see the abuse, suspect the abuse or are told of the abuse by immediately **by phone** or as soon as practically possible & by **written report** sent **within two working days
- if the abuse has occured in a long term care facility**, except a state mental health hospital or a state developmental center, the report shall be made to the **local ombudsman** or the **local law enforcement agency
- if the suspected or alleged abuse occured in a state mental health hospital** or a **state developmental center**, the report shall be made to designated **investigators of State Department of Mental Health** or the **State Department of Developmental Services** or to the **local law enforcement agency
- if the abuse has occurred any place other than one described**, the report shall be made to the **adult protective services agency** or the **local law enforcement agency
5
Q
S.O.A.P.
A
S: SUBJECTIVE
CC/Chief Complaint, HPI/Hx Present Illness, Review of body systems, Medical Hx, Surgical Hx, Family Hx, Social Hx, Current Medications, Smoking Status, Drug/Alcohol/Caffeine use, level of physical activity & allergies
+OLDCHARTS:
- O: Onset
- L: Location
- D: Duration
- CH: Character
- A: Alleviating/Aggravating factors
- R: Radiation
- T: Temporal pattern
- S: Severity
O: Objective
Vital Signs/measurements, Physical Examination, Labs/Diagnostics, Medication List from Records,
A: Assessment
Main S/S & Dx, Differential Dx, Progress, Etiologies, Risk Factors
P: Plan
Therapeutic intervention, Treatment schedule, Home Care, Referrals, Recommendations
6
Q
RECORD KEEPING
(Biomed Review Book)
A
- 60 days to respond to patient request amend records, 90 days to comply w/ release of records
- Error: draw single line, write “error”, sign & date, document correct information
- ONLY signed by health provider
- Records BELONG TO health provider, patient can ask to access &/or amend
- Missed/Canceled appointment: document BOTH appointment book AND medical record
- Appointment Logs: kept beyond Statute of Limitations
- Referral w/ Record Request: written permission patient, chart it (what, when, to whom, make a copy of sent)
- Can serve as legal document (malpractice suit, injury court case)
- if it’s not charted, it didn’t happen
7
Q
HIPAA
(Health Insurance Portability & Accountability Act)
A
- designed to protect patients Personal Health Information (PHI)
- Notice of Privacy practices (NOPP): must be given to every patient at 1st office visit, posted prominently in clinic, & provided to non-patients who request it
- Patient must sign consent form after reading NOPP for permission to disclose PHI to parties disclosed (insurance, police, etc.)
-
office procedures ensure PHI not compromised
- files locked & secured
- computers password protected, screens not visible to others
- No PHI not released w/o written consent
- transmission of PHI securely (no email unless encryption)
- ALL privacy breaches must be documented & followed up on
- maintain records of all disclosures of PHI for 6 years (deceased patients PHI consent form doesn’t expire)
- penalties: $1000/occurrence for leaving PHI unsecured, $250,000/criminal penalty for improper disclosure, up to 10 years prison
- Minors: anyone age 17 & below, UNLESS: emancipated minor, armed forces, married, self-supporting & living alone
- train all employees in HIPAA protocols, name an Information Security Officer
- signed contract for all access to PHI
8
Q
EMERGENT REFERRAL
(IMMEDIATE CARE)
A
If you suspect Pt may have:
- myocardial infarction
- difficulty breathing (no response meds)
- CVA (stroke)
- fever over 105
- suspected fracture
- acute appendicitis
- acute pancreatitis
- pulmonary embolism
- severe pneumothorax
- suicidial depression
- hypertensive crisis
- atrial fibrillation
- pyelonephritis (w/ high fever)
- ectopic pregnancy
9
Q
URGENT REFERRAL
(w/in 24-48 hours)
REFERRAL GUIDELINES
A
- seizure (new onset)
- lung cancer
- breast cancer
- gastroenteritis
- otitis media
- pyelonephritis (w/ mild fever)
- malignant melanoma
- deep vein thrombosis
- neuropathy w/ high levels pain, paresthesia, numbness
10
Q
ROUTINE REFERRAL
(w/in 48 hrs to 7 days)
REFERRAL GUIDELINES
A
- ADHD
- Autism
- Sleep apnea
- Cancer (colorectal, bladder, uterine)
- Radiculopathy w/ mild pain & intermittent paresthesia
- Myasthenia gravis
- Temporomandibular joint disorder (TMJD)
- Heartburn not responding to acupuncture Tx
- Narcolepsy
- Basal Cell Carcinoma
- Erectile dysfunciton
- Cataracts
11
Q
CPT Codes
A
97810: Acupuncture, 1 or more needles, w/o E-stim, initial 15 minutes
97813: Acupuncture, w/ E-stim, initial 15 minutes
12
Q
E&M Codes
(Evaluation & Management Codes)
A
- these codes are based on CPT codes & used for office visits where consultation or examination performed
-
Four levels:
- Problem Focused
- Expanded Problem Focused
- Detailed
- Comprehensive
- levels reflect depth of health care providers history intake & examination
- different fees can be charged based on level of complexity of office visit
13
Q
ICD-10 Codes
(International Classification of Diseases)
A
codes used to describe condition health care provider is treating or “diagnosis” given to patient
- Examples:
- M54.5: low back pain
- M54.2: Cervicalgia (neck pain)
- K21.0: Reflux esophagitis
- J34.990: Exercise induced bronchiospasm (asthma)
- G43.009: Migraine w/o aura, not intractable, w/o status migrainosus
