unit 2 test Flashcards
liability
competent adults who are legally responsible for their actions on the job and in private lives
physicians liability as an employer
grounds and buildings
vehicles used for work purposes
employee safety on the job
standard of care
level of performance expected of health care providers carrying out duties
duty of care
obligations of health care workers to patients/nonpatients (must stay in scope of practice)
reasonable person standard
the standard of behavior that judges a person’s actions in a situation according to what a reasonable person would do in that situation
confidentiality
act of holding information in confidence, not to be released to unauthorized individuals
confidentiality is…
unethical and illegal to breach
privileged communication
information held within a protected relationship (physician - patient)
waiving confidentiality
Third party requests a medical examination for employment
A patient sues a physician for malpractice and records are subpoenaed
A waiver has been signed by patient allowing release of information
Unintentional Tort of Negligence
any deviation from the accepted medical standard of care causing injury to the patient
- basis for professional malpractice claims and most common liability in medicine
Malfeasance
the performance of a totally wrongful and unlawful act
Misfeasance
the performance of a lawful act in an illegal or improper manner
Nonfeasance
the failure to act when one should
four elements to prove negligence
Duty - the person charged owed a duty of care to the accuser
Dereliction - the health care provider breached the duty of care to the patient
Direct cause - the breach of duty of care to the patient caused the injury
Damages - there is a legally recognizable injury to the patient
- awarded to plaintiff when defendant is found guilty of tort
phases of lawsuit
Pleading Phase - delivery of complaint is issued
Interrogatory or pretrial discovery phase - subpoena (court order) and deposition (sworn testimony) may occur
Trial phase
Appeals phase
Witness Testimony
Fact - witness provides facts he or she has observed
Expert - experts in particular fields have the education, skills, knowledge, and experience to give expert witness
Alternative Dispute Resolution (ADR)
Techniques for resolving civil disputes without going to court
- Uses mediation and arbitration
4 C’s of Medical Malpractice Prevention
Caring
Communication
Competence
Charting
7 Common Reasons for Malpractice
Cancer misdiagnosis/failure or delay
Birth injury/negligent maternity care
Wrong diagnosis or misdiagnosis of negligent fracture or trauma
Delay in diagnosis or failure to consult in timely manner
Medication errors or medication malpractice from negligent drug treatment
Malpractice resulting from physican’s negligent procedures or surgical errors
Failure to obtain informed consent
Actions that Might Prevent Litigation
Explanation and apology
Correction of the mistake
Financial compensation
Correct treatment at the time
An admission of negligence
Disciplinary action against medical personnel involved
Honesty
Investigation by the hospital
Documentation
Referrals
Missed appointments
Dismissals
Treatment refusals
All other patient contact
Denial of wrongdoing
stating innocence
Affirmative defenses
allows the accused to present evidence that the patient condition was caused by another factor
- contributory negligence
-comparative negligence
-assumption of risk
- emergency
contributory negligence
plaintiff caused/contributed to their own injury
Comparative negligence
plaintiff was partially responsible for their own injury
Assumption of risk
- patient knew the inherent risk prior to treatment
Emergency
HCP who help in an emergency situation at the scene was not held liable
Technical defense
hinge on legal technicalities rather than factual evidence
Res judicata
a claim cannot be retried between the same parties if it has already been legally resolved
Statute of limitations
a suit cannot move forward if a certain period of time has elapsed
- varies from state to state
- specifies 1-6 years
-2 years is most common
when does statute of limitations begin?
- the day alleged negligent act was committed
- when the injury resulting from alleged negligent act was discovered
- the day the physician-patient relationship ended or last day of treatment
Quality Improvement/Assurance
program to uphold the quality of patient care and reduce liability risk
Professional Liability Insurance
covers costs of defending a medical malpractice lawsuit up to policy limit
what is the cost of insurance based on?
physician’s speciality and dollar amount of the policy
why is professional liability insurance required?
to obtain hospital privileges or work in a HMO
Medical record
collection of data recorded when a patient seeks medical treatment
what does a medical record do?
-Required by licensing authorities and provide a format for tracking, documenting, and maintaining patient communication data
-Provide documentation of a patient’s continuing health care from birth to death
-Provide a foundation for managing a patient’s health care
-Serve as legal documentation in lawsuits
-Provide clinical data for education, research, statistical, tracking, and assessing the quality of health care
5 C’s of documentation
Concise
Complete (and objective)
Clear (and legibly written)
Correct
Chronologically ordered
legality of medical records
Usually prevail over a patient’s recollection of events during a trial
Legal if kept on paper, microfilm, computer tape or disks
Should not released to a third party without written permission from patient
Improper documentation can lose a medical liability case
ownership of medical records
Owned by the facility that created them
Patient owns the information they contain
On signing a release, patients may obtains copies of records under HIPPA ruling
storage of records
Records are kept for 2-7 years
Physicians retain records indefinitely as they affect future treatment
routine release of medical information
Insurance claims
Transfer to another physician
Use in a court of law
authorization to release records
Should be in writing
Include patient name, address, and date of birth
Parent or guardian should sign
Only information requested should be released
consent
patient gives permission for the physician to examine him or her to perform tests that aid in diagnosis and to treat for a medical condition
doctrine of informed consent
Legal basis for informed consent
Outlined in a state’s medical practice acts
informed consent information
Proposed modes of treatment
Why treatment is necessary
Available alternative modes of treatment and risks of these modes
Risks involved if treatment is refused
cannot give informed consent
Minors
Mentally incompetent persons
Persons speaking limited or no english
good samaritan acts
law that waives consent in medical emergencies
electronic health record
Contains same information as a medical record, but electronically
Cautions regarding confidentiality
Use of photocopiers, fax machines, printers and computers
