Chapter Three: Chapter Three Medical Ethic and Liability


Ethics : Ethics Rules or principles which govern right conduct Medical Ethics The values and guidelines governing decisions in medical practice


Licensure Requirement for a Physicians : Licensure Requirement for a Physicians Be of legal age Be of good moral character Have graduated from an approved medical school Have completed an approved residency program or its equivalent be a resident of the state where the pysician is practicing Have passed the oral and written examinations administered by the National Board of Medical Examiners and the state where the physician is practicing


Medical Assistants Code : Medical Assistants Code Governed by the AAMA code of Ethics render service with full respect for the dignity of humanity respect confidential information obtained through employment unless legally authorized or required by responsible performance of duty to divulge such information Uphold the honor and high principles of the profession and accept its disciplines Seek to continually improve the knowledge and skills of the medical assistants for the benefit of patients and professional colleagues Participate in additional service activates aimed toward improving health and well-0being of the community


Medical Assistants Creed: Medical Assistants Creed I believe in the principles and the purposes of the profession of medical assisting. I endeavor to be more effective I aspire to render greater service I protect the confidence entrusted to me I am dedicated to the care and well-being of all people I am loyal to my employer I am true to the ethics of my profession I am strengthen by compassion, courage and faith


Confidentiality Agreements : Confidentiality Agreements Every health care professional should be required to sign one and should be signed at every employment anniversary When signed an agreement acknowledges the assistants understanding of the facility’s policy regarding confidentiality of health information


Confidentiality Agreements: Confidentiality Agreements Under some circumstances the physician is required to file reports containing confidential information to state department s of health or social service. These are called statutory reports.


Confidentiality Agreements : Confidentiality Agreements Examples of reports : Injuries resulting from violence such as gunshot or stabbing Occupational illnesses such as chemical poison Communicable diseases including AIDS Case of food poisoning


Maintaining Patients Privacy: Maintaining Patients Privacy Do not leave confidential papers anywhere on the copier Always shred copies Always verify the telephone number of the receiving location before faxing confidential information Never fax confidential information to an unauthorized person or in a room where others can observe the material Do not leave the a computer monitor unattended if confidential information is displayed on it It is recommended that you not send confidential material via email Do not print confidential material on a printer shared by other departments Do not leave a printer unattended while printing confidential material


Patients Bill of Rights : Patients Bill of Rights Receive considerate and respectful care Receive complete ,current information concerning his or her diagnosis treatment and prognosis Receive information necessary to give informed consent prior to the start of any procedure and/or treatment Refuse treatment to the extent permitted by law Receive every consideration of his or her privacy


Patients Bill of Rights: Patients Bill of Rights Be assures of confidentially Obtain reasonable responses to requests for service Obtain information about his or her ealth care Know whether treatment is experimental Expect reasonable continuity of care Examine his or her bil and have it explained Know which hospital rules and regulations apply to patient conduct


Medical Compliance Plans : Medical Compliance Plans Medical Compliance Plan addresses: Coding and billing Reasonable and necessary services Documentation Improper inducements, kickbacks, and self-referral


The Medical Compliance Plan: The Medical Compliance Plan OIG Program Guidelines suggests seven basic elements Written policy and procedures Designation of a chief compliance officer Training and education programs Effective line of communications Auditing and monitoring Well-publicized disciplinary directives Prompt corrective action for detected offenses


Medical Assistant role in Compliance : Medical Assistant role in Compliance Helps the practice stay in compliance by: Accurate data entry Accurate documentation Timely filing and storing of records Prompt reporting of errors or instances of fraudulent conduct


Legal Terminology: Legal Terminology Emancipated Minor -an individual who is no longer under the care, custody or supervision of parents . Competent Individual - One that is fit, able to make decisions capable of making decisions


Legal Terminology: Legal Terminology Tort - any number actions done by one person or a group pf persons that causes injury to another. Offer Takes place when a component individual indicates desire to be a patient Acceptance takes place when an appointment is made and the physician examines the patient Defamation - to attack the reputation of an individual or a group of individuals


Legal Terminology: Legal Terminology Implied Consent Patient enters into agreement by coming to see the doctor Civil Laws - Deals with laws governing property ownership, corporation and inheritance Reciprocity - License granted in a new state because of equal requirements Contract Law - Patient-Physician relationship considered contract


Living Will : Living Will A document in which an individual expresses his or her wishes regarding medical treatment. It is legal only if the person is component to create such a document Two witness have attested to its accuracy


Negligence : Negligence Is doing or not doing something that a reasonable person would do or nor do in a given situation


Abandonment : Abandonment A physician may be sued for this if he or she has taken on the care of a patient and then is not readily available to continue with the care.


The Good Samaritan Act : The Good Samaritan Act Is to protect individuals from charges of neglect or abandonment in emergency situations when no compensation is received . More importantly physician can give care under emergency situations without the fear of being charged with neglect .


3 parts of  Patient-Physician Contract : 3 parts of Patient-Physician Contract The offer - desires to be patient Acceptance - Appointment is given - Physician examines the patient Consideration - Payment for services


Express Consent is Required : Express Consent is Required Purposed surgery or other invasive treatments such as lumbar punctures, and biopsies Use of experimental drugs Use of unusual procedures that may involve high risk


To help ensure confidentiality : To help ensure confidentiality To help protect confidentiality: Avoid any conversation, either in person or on the telephone with a patient or others about any aspect of treatment , patient records or financial arrangements . When speaking on the phone avoid using the caller’s name or the name of the patient Being careful when calling patient about test results –NEVER leaving a message on the answering machine or with any other person except to request a return call from the patient Always keeping documents shielded from view in areas where fax machines, copy machines and printers are located.


To help ensure confidentiality: To help ensure confidentiality To help protect confidentiality: Always removing documents from fax area, copy area and shredding them rather than putting materials in the trash Protecting computerized records and other information. Do not leave information showing on any unattended screen. Be careful of access to the network if the computer shares programs and data files.


Medical Records : Medical Records Holds all data about the patient . Includes the following items: Chart Notes History and Physical ( H & P ) History refers to complete medical history Physical refers to initial results of a physical examination by the physician Referral and consultation letters Medical Reports Correspondence Clinical forms Medication List


Medical records : Medical records A patient record meets the following criterion - personal information such as name, address, occupation, martial status and insurance carrier. - patient's personal family, socio-cultural and medical history - all details of physical exanimations, laboratory and X-rays findings diagnoses and treatments - consent forms for procedures done and authorizations


Reasons for the need to keep Medical Records : Reasons for the need to keep Medical Records To give adequate care May be used to research into certain illnesses or forms of treatment Must be complete for protection in case of a lawsuit As main source of information for coordinating and carrying out patient care among all providers involved with the patient As evidence of the course of an illness and a record of the treatment being used


Reasons for the need to keep Medical Records: Reasons for the need to keep Medical Records As a record of the quality of care provided to patients As a tool for ensuring communication and continuity of care from one medical facility to another As legal record for the practice As the main record to ensure appropriate


SOAP method of documentation: SOAP method of documentation Subjective Findings Patient’s description of the problem or complaint May include the following sub headings Chief Complaint (CC) History of present illness (HPI) Past medical history (PMH) Family History (FH) Social History (SH) Review of systems (ROS)


SOAP method of documentation: SOAP method of documentation Objective Findings Results of a physical examination by the physician Subheadings include: VITAL SIGNS (VS) GENERAL General description “ well developed….” HEENT NECK CHEST HEART LUNGS ABDOMEN


SOAP method of documentation: SOAP method of documentation Assessment Is the physician’s interpretation of the subjective and objective findings . Another term used Diagnosis (DX) and impression Sometimes uses the term rule out (R/O)


SOAP method of documentation: SOAP method of documentation Plan Or treatment section lists the following information regarding the physicians treatment of their illness Prescribed medications and their exact dosages Instructions given to the patient Recommendations for hospitalization or surgery Any special tests that need to be performed


Steps to be followed to prevent unauthorized medical information : Steps to be followed to prevent unauthorized medical information Confidentially applies to patient regardless of their personal lifestyle or characteristics Be aware of laws ( federal, state, and local) ordinances regulations and rules as well as public health programs All requests from a third party require the patients signature for medical information to be released . Keep a current “signature on file” form in the front of a patients record


Steps to be followed to prevent unauthorized medical information: Steps to be followed to prevent unauthorized medical information Never give out medical information about a patient you are not certain that a signed permission form exists Patients should be provided with medical information regarding their diagnosis and treatment and it is their decision to release or not to release that information If you are legally required to release medical information regarding a patients of the seriousness or risk of diseases spreading to others it should be discussed with the patient


Changes to medical records : Changes to medical records A single line draw through the incorrect information and add your initials , date and reason for the changes . Should appear in chronological order


Viewing of Patients records by Patients : Viewing of Patients records by Patients Should be done when the doctor is there to interpret medical terms or abbreviations


Office Procedures that have caused problems in malpractice suits : Office Procedures that have caused problems in malpractice suits Procrastination or delay in filing lab test results or reporting them to the physician Incomplete medical records Illegible records Unexplained altered medical records Faking or forging a document or signature Loss of records