Unit 2: Guiding questions 3 Flashcards
What do you need to remember about the patients medical record?
- legal document that is evidence
- record is presumed true
- documentation should reflect scope of practice thats within the legal description provided by the state
- any questions that surfaces in a legal proceeding can be answered based on context of documentation
- single most important evidence of the PTs judgement, actions, skills, decision making
- overseeing health care professional for the patient is responsible to keep health information accurate, timely, relevant, secure
Documentation Supports or Refutes Medical Malpractice
- prove that the health care provider was negligent
- nonverbally explain how the provider met the professional standard of care (duty)
- if its not documented, it didn’t happen
Legal Document Problems and Pitfalls
- parrot documentation
- technical omissions
- illegible entries
- undefined abbreviations
- lack of substance
- lack of information to support if standard of care has been met
Components of informed consent and how to document it
- a clear explanation of the RISKS associated with the therapy
- expected BENEFITS from therapy
- anticipated COSTS
- reasonable ALTERNATIVES to the rec. therapy
Confidentiality
all information regarding the patients care must be kept confidential and in a secure area
Incident report is NOT part of pts medical records and CAN be used in litigation…
what are some do’s and don’ts about incident reporting
- notify referring physician immediately bc S&S is may develop or worsen
- ensure pt receives appropriate care after the incident
- record only factual information for supervisor
- DONT discuss relative guilt or innocence
- DONT make inferences related to cause in the report
- DONT discuss with pt after event
What governs how long medical records are to be retained?
HIPPA requires a covered entity to retain required docs for ____ yrs from the date of its creation or the date when it was last in effect
- STATE LAWS
- 6 yrs
Statute of Limitations
time limit after an incident by which an individual must file a lawsuit
retention periods must exceed statutes of limitations
Purpose of the State Boards of PT Practice
- review complaints!! brought against pts, ptas, and students for violation of the PRACTICE ACT
- disseminates rules and regs governing the progession of PT
- oversee the state licensure of pts and ptas
General Supervision:
PT is NOT required to be on site for direction and supervision but MUST BE AVAILABLE by telecommunication
Direct Supervision:
PT is PHYSICALLY PRESENT and immediately available for direction and supervision. PT will have DIRECT contact with pt during each visit
Direct Personal Supervision
PT or PTA (if allowable), is physically present immediately available to continuously direct and supervise tasks that are related to pt
If there are conflicts in the regulatory hierarchy, which rule should you follow?
the most restrictive law
Effects of fraud, waste, and abuse in PT Practice
- over utilization of services
- increased costs for payers
- corruption of medical decision making
- unfair competition
- harm to the patient
- reduced reputation of PT practice
Fraud:
INTENTIONAL deception or misrepresntaion that a person does to gain a benefit which they are not entitled to
(knowingly billing for services not furnished, altering claims forms to increase payment, falsifying documentation
Abuse:
payment for items or services that the provider isnt entitled to and for which the providor has NOT INTENTIONALLY misrepresented facts to obtain payment
(billing services that arent medically necessary and/or do not meet professionally recognized standards, unbundling services/billing)
