Transcript Law, Documentation & Ethics

Law, Documentation
& Ethics
RTEC 93
Veinpuncture and Pharmacology
for Radiologic Technologists
ASRT
 Includes
venipuncture and IV
medication administration in the
curriculum guidelines for the
educational opportunities offered
to technologists.
 Standards of Practice for
Radiography
American College of Radiology
(ACR)
 Additional
support for the
administration of medications
and venipuncture as part of
the technologist’s scope of
practice if found in the 1987
Resolution No. 27
Veinpuncture Laws
 CALIFORNIA
HEALTH AND
SAFETY CODE
 HEALTH
AND SAFETY CODE
SECTION 106955-107111
Hospital Policies for
Radiologic Technologists
 Competency
in venipuncture
and IV contrast administration
requires the completion of a
formal course of instruction
and supervised clinical practice
and evaluation
Standard of Care


Degree of skill (proficiency), knowledge,
and care ordinarily possessed & employed
by members in good standing within a
profession.
To test whether the standard of care has
been met, one must determine what a
reasonable, prudent practitioner would
have done under similar circumstances.
Causes of Legal Action


Approx 10% of all medical negligence
claims are somehow related to diagnostic
imaging.
Medical Negligence – failure to use such
care as a reasonably prudent health care
professional would use in similar
circumstances.
Four Elements to Prove
Negligence
1.
2.
3.
4.
Must establish a duty to the patient by
the health care provider
Breach of this duty by an act or by failing
to perform some act.
A compensable injury
A causal relation between the injury and
the breach of duty.
Cause of Legal Action

Tort – Civil wrong committed by one
individual against another. May be
classified as either intentional or
unintentional. This type of claim arises
from a breach of duty. ex: less than optimal
care, threatened, or injured in department

Usually based upon legitimate concerns of
negligent care or claims of assault,
battery, or false imprisonment.
Cause of Legal Action


Assault – Any willful attempt or threat to
inflict injury on the person and any
intentional display of force that would give
the victim reason to fear or expect
immediate bodily harm.
Battery – An unlawful touching of another
that is without justification or excuse. Ex:
a technologist performs an exam or touches a
patient without that patient’s permission, even if
no injury arises from such contact.
Cause of Legal Action

False Imprisonment – Conscious restraint
of another without proper authorization,
privilege, or consent. The more common
claim of false imprisonment arises when a
person is restrained against his or her will.

Defamation – Holding up a person to
ridicule, scorn, or contempt in a
respectable & considerable part
of the community.
Corporate Liability



Requires the hospital or health care entity
to be responsible for the quality of care
delivered to consumers.
Health care corp. must assess & evaluate
the quality of care delivered & must be
prepared to make changes as needed.
The corp. may be required to intervene if
suboptimal care is being provided by one
of its independent contractors.
Informed Consent



A person’s agreement to allow something
to happen (i.e surgery) that is based on
full disclosure of the facts: knowledge of
benefits, risks, and alternatives to the
procedure.
Required when a patient is subjected to
any type of invasive procedure.
If the pt consents to a procedure & then
revokes the consent, the doctor must stop
the procedure.
The Law
Every human being of adult years and
sound mind has a right to determine what
shall be done with his own body and a
surgeon who performs an operation
without his patient’s consent commits an
assault, for which he is liable in damages.
Six functions of this Law
1.
2.
3.
4.
5.
6.
Protects individual autonomy
Protects the patient’s status as a human
being
Avoids fraud and duress
Encourages health care practitioners to
carefully consider their decisions
Fosters rational decision making by the
patient, and
Involves the public in medicine
The Health Record in Court

The radiograph as evidence



Dark/light radiograph
Mis-marked films
Wrong patient information
Documentation

In court, if you testify that you properly
assessed the patients medical risk and
obtained consent from the patient verbally
prior to the examination; will that serve as
meeting the Technologist Standard of
Practice?
Documentation
Federal requirements and the JCAHO (Joint
Commission on Accreditation of Healthcare
Organizations) require that the medical
staff of an institution have bylaws, rules
and regulations that include a provision for
accurate and complete medical records
with the original copies of documents in
the patient record.
The record is a means of communication
between the healthcare professionals who
are treating the patient.
Must Include:





Patient identification date
Medical history of the patient, including
chief complaint; present illness or injury;
relevant past, family and social histories;
and inventory by body systems
Report of relevant physical examination
Diagnostic and therapeutic orders
Clinical observations, including results of
therapy



Reports of diagnostic and therapeutic
procedures and test as well as their results
Evidence of appropriate informed consent
(when consent is not obtainable, the
reason should be entered in the record)
Conclusions at termination of
hospitalization or evaluation of treatment,
including any pertinent instructions for
follow-up care
Charting Drug Information


Any time a drug is administered to an
inpatient it must be charted
Information includes:




Drug name
Dose of the drug
Route of administration (if parenterally, then
the side of injection)
Date & Time
Documentation


The five rights of medication
administration is to be included in every
patient’s permanent medical record.
The size, type and location of the needle,
number of venipuncture attempts; and the
identity of the health care personnel who
performed the procedure.
Document Meds Given

5 rights of medication administration:
1.
2.
3.
4.
5.
The
The
The
The
The
right
right
right
right
right
patient
medication
route
amount
time
Example

4-25-2007 at 0900 a venous access of Mr.
Jones was performed using an 20-gauge
antiocatheter. The access was established
in the antecubital of the left arm after one
attempt. Then 100 ml of Isovue 300 was
administered by IV push via the access.
The patient tolerated the injection
procedure and medication without
complaints of pain and with no
unexpected side affects. K. Clark, R.T.
Charting Exam Completion


M.D.’s order in patient’s chart should be
verified prior to examination
Document exam completion next to M.D.’s
written order

Ex: 4/25/07, 1300, 2 view CXR complete
K. Clark (RT)
HIPPA


The Health Insurance Portability and
Accountability Act of 1996 mandates that federal
laws or regulations ensure the confidentiality of
medical records.
Patients or representatives should have access
to all records except in the event the provider
feels that it is not in the best interest of the
patient’s health to have access or if the
knowledge of the health care information could
cause danger to the life or safety of any person.
HIPPA

Within radiology:
Technologists are sometimes asked by
patients if they can examine their records
while in transit, waiting for a procedure or
undergoing an examination. The record
information should not be shared with the
patient in this fashion as this may lead to
misinterpretation of information.
Documentation

As applied to radiology:


Assess the order: procedure requested,
identifying information, doctor
The report: results are kept in patient chart
The Importance of a
Professional Ethic
Ethics: the systematic study of
rightness and wrongness of
human conduct and character as
know by natural reason
Professional Ethic: the ethical
conduct of a profession
Ethical Dilemmas
A situation requiring moral judgment
between two or more alternatives; there
are two or more competing moral norms
present, creating a challenge about what
to do
Ethical Analysis




1.
2.
3.
4.
identifying the problem
developing alternative solutions
selecting the best solution
defending your selection
Professional Ethic
 Conduct must support the emotional and
physical needs of the patient
 Patient privacy and dignity or even the
simple right to be told the truth must be
adhered to
 Assist in providing accurate information
which enables physicians to make proper
diagnosis
REMEMBER
Radiology Technologist are legally liable for
their actions in the daily performance of
diagnostic procedures.
Health care practitioners who do not
remain current in the field or who do not
follow the accepted standard may be
liable under the legal theory of medical
negligence.
Identifying the Problem
 Thoroughness in problem identification,
looking at every possible twist or nuance
in a given situation
Developing Alternative
Solution
 Attempt to exhaust all possible pathways
to a resolution of the dilemma, taking
care to view the dilemma from the
perspective not only of the patient and
the patient’s family but also the health
care professionals and administrators to
whom they entrust their care.
Selecting the Best
Solution
 Most challenging step
 It is a personal activity that involves
choosing an alternative not only based
on widely held moral stands but one that
is also in full accord with your own
individual value system
Defending Your Selection
 Explain the basis for your ethical decision
in terms that you can justify to colleagues
and patients alike
Situation Judgment Tests – SJT’s
“I Think Dr. Jones Misread the Film”
You have just finished a routine radiologic procedure on
Mrs. Green. As you develop the film, it becomes clear
that Mrs. Green is probably suffering from a rare form
of bone disease. Dr. Jones, a young resident, glances
at the film and smiles. “I didn’t think Mrs. Green had
anything to worry about,” he says. “That joint pain she
was complaining about must be all in her head.” Later,
you see Dr. Jones talking to Mrs. Green’s family. He is
smiling and joking with them as he signs Mrs. Green’s
discharge papers. Shaken, you mutter to yourself, “I
think Dr. Jones misread the film.” What should you do”