Unit 2 Legal Aspects

Question 1

What do you need to always remember about the patient’s medical record?
Legal document that is __________
Patient record is presumed ___________
Documentation should reflect __________________ that is within the legal description provided by the state
Any question that surfaces in a legal proceeding can be answered based
________.
Single most important evidence of the PT’s __________
Overseeing health care professional for the patient is responsible to keep health
information __________

Answer 1

admissible as evidence in a court of law
true
scope of practice
on the content of your documentation
judgment, actions, skills and decision-making
 accurate, timely, relevant, secure, and confidential

Question 2

Documentation Supports or Refutes Medical Malpractice
Prove that the health care provider was___________.
Nonverbally explain how the provider met the __________ (duty).
“If it’s not documented, ________________”

Answer 2

negligent
prevailing professional standard of care
it didn’t happen

Question 3

What should your documentation contain?

Answer 3

• Detailed enough so another practitioner can assume the care of the patient with no questions asked
• Clearly identify important characteristics of the patient, support the diagnosis, justify treatment, and establish outcomes reached
• All significant information about the patient should be included; all communication among caregivers and other health care providers
• Continuity of clinical decisions; implementation of plans; evidence of patient’s care; goals achieved
• Reasonable and necessary skilled care
• Treatment notes reflect what care the patient received and patient response
• Progress notes refer back to initial examination and goals to demonstrate progress
• Any refusal, inability to take part, missed visits, and why

Question 4

What are some common legal documentation problems and pitfalls?

Answer 4

*parrot documentation
*technical omissions
*illegible entries
*undefined abbreviations
*lack of substance
*lack of information to support if standard of care has been met

Question 5

Electronic Health Records should always be ____________ protected, with
______________ screens and comply with ________________.

Answer 5

password; privacy; federal and state regulations for security and privacy measures

Question 6

What are the components of informed consent and how do you document it?

Answer 6

• Document: PT gave information; Patient understood & consented to the proposed treatment
• A description of the treatment to be provided
• A clear explanation of the risks that may be associated with the therapy
• Expected benefits from the therapy
• Anticipated timeframes
• Anticipated costs
• Reasonable alternatives to the recommended therapy
• For PTs varies by state

Question 7

Medical Record Content

Answer 7

 Signed consent for treatment
 Referral if indicated
 Privacy notice receipt acknowledgement
 Insurance verification
 Copies of any pertinent reports
 Evaluations/reevaluations
 Plan of care
 Daily visit/encounter notes
 Progress notes
 Equipment information; Flow sheet
 Discontinuation summary/conclusion of episode of care
 Letters/communications
 No show/cancellation
 Service, billing, activity logs
 Letters of medical necessity

Question 8

All information regarding the patient’s/client’s care must be kept
____________ and in a ________________.

Answer 8

confidential; secure area with access limited to appropriate staff

Question 9

The incident report is not part of the patient’s medical record and can be used in litigation. What are some of the do’s and don’ts about incident reporting?

Answer 9

• Notify referring physician or other health care provider immediately, existing signs/symptoms worsen, or new signs/symptoms develop
• Ensure patient/client receives appropriate care after incident
• Record only factual information; give report to supervisor
• Do not discuss the relative guilt or innocence of anyone involved or problems with equipment used
• Do not make inferences related to cause in the report
• Do not discuss with patient after event

Question 10

Maintaining Patient Records
 ______________ govern how long medical records are to be retained
 There are legal requirements for retention of ___________ which may include medical records
 HIPAA requires a covered entity to retain required documents for ______________ from the date of its creation or the date when it last was in effect
 ____________________: time limit after an incident by which an individual must file a lawsuit; retention periods must exceed statutes of limitations
 Regulations in Medicare Conditions of Participation

Answer 10

state laws
business records
6 years
statute of limitations
Regulations in Medicare Conditions of Participation