Transcript Medical Law and Ethics Lesson 3: Documentation

Medical Law and Ethics
Lesson 3:
Documentation and Regulations
Lesson
Objectives
Lesson Objectives
Upon completion of this lesson, students
should be able to …
 Discuss the role of the medical assistant
relating to legal issues in the medical
office.
Documentation
 It
is critical to carefully document
what happens in the medical office.
If an action is not recorded on the
medical chart, then it is considered by
the court not to have been performed.
Information Documented in a
Patient’s Chart
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Calls and visits
Treatments
No-shows
Appointment
cancellations
Medications
Prescription refills
Vital signs
Other pertinent
information
Cautions with Documentation
Be careful with fax transmissions of
medical records
 Receiving fax must be located in a
restricted area
 A disclaimer should be placed on the fax
cover explaining that records are
confidential
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Court Testimony
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If you are asked to testify in court…
◦ Be professional
◦ Remain calm, dignified, and serious
◦ Always tell the truth
◦ Do not answer questions you do not
understand
◦ Just present the facts about the case
Reports Physicians Must Provide
Births
 Stillbirths
 Deaths
 Communicable illnesses or diseases
 Drug abuse
 Certain injuries
 Abuse of child and adults
 Gunshot and knife wounds
 Animal bites
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Mandated Reporter
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Must report abuse or risk fines and/or jail
time
Child Abuse
Physicians have a
duty to report
questionable injuries
of children
 Requirements differ
by state
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These injuries
include:
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Bruises
Fractured bones
Burns
Malnutrition
Poor growth
Lack of hygiene
Elder Abuse
Physicians have a duty to report
questionable injuries of the elderly
 These requirements include:
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◦ Physical abuse
◦ Neglect
◦ Abandonment
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Requirements differ by state
Drug Abuse
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Abuse of prescription
drugs must be reported
Patient may go to several
different doctors for the
same drug
A physician should always
see the patient before
prescribing drugs
Form DEA 224
Used by physicians to register with the
DEA
 Allows physicians to prescribe, dispense,
or administer controlled substances
 Renewal is required every 3 years
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Requirements for Controlled
Substances
Controlled drugs must be kept in a
double-locked cabinet
 Any theft must be immediately reported
 Physician’s black bag and prescription
blanks should always be stored in a
secure, locked location
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Schedule for Controlled
Substances
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Schedule I (cocaine, LSD)
◦ Highest potential for addiction and abuse
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Schedule II (Morphine)
◦ High potential for addiction and abuse
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Schedule III (anabolic steroids)
◦ Moderate to low potential for addiction and abuse
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Schedule IV (valium)
◦ Lower potential than Schedule III drugs
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Schedule V (tylenol w/codeine)
◦ Low potential for addiction and abuse
Role of the Medical Assistant
Does not dispense controlled substances
 Must be knowledgeable about the
regulations of the drugs
 Only licensed personnel are permitted to
dispense drugs
 Always report any unusual patient
behavior indicating addictive drug use
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MA’s Role Related to
Confidentiality/Privacy Issues
Never make any statements that could be
interpreted as an admission of fault
 Do not remain silent if you are aware of
illegal activity
 Do not participate in negative discussions
of the physician with patients
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If you are aware of illegal activity and remain
silent, you may be liable.
MA’s Role Related to
Confidentiality/Privacy Issues
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Never discuss anything
about the patient
outside of the office
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Make sure that a female
MA is present when the
physician (male or
female) examines a
female patient
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Treat all patients with
dignity and respect
MA’s Role Related to Office
Management
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Treat all patients with
courtesy and dignity
Log and return
telephone calls
promptly
Explain any delays to
patients
Offer to set up another
appointment if the delay
will be very long
MA’s Role Related to Office
Management
Never make promises
regarding what the
physician can do
 Carefully explain all fees
and responsibilities for
bills
 Relay any concerns
about bills from the
patient to the physician
 Relay patient comments
to the physician
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MA’s Role Related to
Documentation
Carefully sign or initial every note
 document the no-show’s
 Document referrals to another physician
 Follow up to make sure the patient did see the
referral physician
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Medical documents are legal documents and may be
used in a court of law.
MA’s Role Related to
Documentation
Document all patient
contacts, including
telephone prescription
refills and tests and
procedures that have
been ordered
 Call all patients the day
after surgery to check
on their progress and
document this call
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MA’s Role Related to
Documentation
Record all care and
treatment given as soon
as possible
 Be sure the physician
sees and initials all
diagnostic reports
before they are filed
 Provide all patient
instructions in writing
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MA’s Role Related to Drug
Regulations
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May administer medication
only under the direct
supervision of a physician
Follow the Controlled
Substances Act
Know state laws
Secure the supply of
prescription pads from theft
at all times
MA’s Role Related to Drug
Regulations
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When preparing
medications for
administration, check
the medication three
times:
◦ Before removing it from
the shelf
◦ Again, before preparing
the dosage
◦ Before returning the
medication to the shelf
MA’s Role Related to Certification
and Licensing
Know the limits of
certification and standards of
care
 Never perform any
procedures for which you are
not trained or qualified
 Do not diagnose or prescribe
drugs over the telephone
(even OTC drugs)
 Do not call yourself a “nurse”
or allow anyone else to refer
to you as one
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Continue your education
and training to maintain
your skill levels.
MA’s Role Related to Informed
Consent
Physician must explain all
procedures to the patient
 MA is responsible for making
sure there is a signed consent
form
 Never have a patient sign a
document that he or she does
not understand
 Obtain a parent/guardian’s
signature before providing
care to a minor except in the
case of an emergency
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File signed informed
consents immediately!
MA’s Role Related to Safety Issues
Maintain a safe
environment
 Report any safety
hazards at once
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If you knowingly overlook a hazard you could be found
guilty of negligence!
Go to ppt lesson 4
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Medical Ethics