Introduction to Allied Health, Law and Medical Offices

Outpatient service centers- provides consultations, treatments and medications Some services that these centers provide are: minor surgeries and procedures, therapies, diagnostic testing, and preventive services. A medical administrative assistant, or MAA, performs typical clerical duties along with scheduling appointments, electronic medical coding, filing insurance claims, maintaining records, and billing. In an outpatient services setting the MAA may • Check in patients • Answer and make calls • Schedule patients for appointments • Conduct patient interviews prior to appointments • Work with patient charts and electronic medical records • Monitor inventory and order supplies    A Physical Therapy Aide assists patients with the preparation for therapy under the direction and supervision of physical therapists. In an outpatient services setting a physical therapy aide may prepare the treatment area for upcoming therapy sessions, clean the therapy area, assist patients with walking, sitting, or standing, push patients in wheelchairs, set up equipment for patients’ therapy, and perform basic office and clerical duties. An Occupational Therapy Aide or OTA performs clerical duties and facilitates treatment by providing support for the Occupational Therapist or Occupational Therapist Assistant. In an outpatient services setting an occupational therapy aide may assist staff occupational therapists in their treatment of assigned patients, prepare the patient, treatment area, or equipment for therapy, maintain a safe, clean environment, and perform ongoing inventory of equipment and materials to ensure adequate supply. An Optician follows prescriptions written by an optometrist and assists customers in selecting the best eyewear or contact lenses. In an outpatient services setting an optician may follow prescriptions written by an optometrist, assist customers in their selection of eyewear or contact lenses for their desired use, like fashion, safety, or sports, measure the customers’ eyes, face, and distance between their pupils, inform customers of proper use and maintenance of eyewear or contact lenses, maintain inventory and business records, and perform other necessary office-related tasks. A Dental Assistant performs basic clerical duties and assists with patient’s dental care in a dental office. In an outpatient services setting dental assistants may perform basic clerical duties, assist the dentist during procedures, take and develop xrays, collect patient history and vital signs, prepare and sterilize instruments and equipment, help patients feel comfortable before, during, and after treatment, review instructions with patients for oral care following surgery or other dental treatment procedures, perform various tasks such as taking impressions of patients' teeth, and teach oral hygiene and oral health. A Pharmacy Technician supplies or assembles medicines and provides information under the pharmacist’s supervision. In an outpatient services setting a pharmacy technician may supply medicines to patients, assemble medicines for prescriptions, provide information to patients, manage areas of medical supply, such as dispensaries, and supervise other pharmacy staff. A Medical Biller and Coder assigns codes for medical services and creates billing information for insurance, third-party payers, and sometimes patients. In an outpatient services setting a medical biller and coder may examine patient medical records, assign codes to the diagnoses and procedures performed, and create the required documentation for reimbursement. Many work remotely. Medical billers and coders don’t

Community, Ambulatory, Home Health Profession- Personal Care Aide Can care for a family member or become employed directly by a family to assist a specific person Home Aide assist with activities of daily living,bathing,dressing and food prep monitor and report daily health and behavorial changes document meds, activity, behavior and intake react appropriately in an emergency Medical Admin Assistant checks in patients answers and make calls Schedules appointment works with patient charts and electronics medical records monitors and order inventory and supplies Med Assistant performs routine clinical duties under employment by a physician, nurse take vitals-blood pressure, pulse, and respirations take medical histories prepare patients for medical tests or procedures assists doctors during procedures sterilize medical instruments Medical Transcriptionist translate medical history and physicals discharge summeries operative report autopsies diagnostic report Optician fitting and dispinsing eyeglasses and contact lens may design the actual frame or lens dispense contacts or frames

Key Points MAA work in doctors offices and perform taks like answering phones and schedule appointments Medical assistants may take vital signs, prepare patients for tests Medical transcriptionist translate voice recordings into text including discharge sunmmeries, medical histories, HHA- assists individuals with daily living, monitor health status Optians- dispense prescription contact lens and glasses  

Role of Healthcare Professionals in Hospital Practice- Health Information Management Medical Biller and Coder Occupational Therapy Aid Pharmacy Tech Physical Therapy Health Information Manager(HIM)-    process, analyze and report vital info to healthcare industry responsible for organizing analyzing, and managing different types of healthcare info patients diagnoses, result of lab tests, x-rays and treatments plans monitor and maintain EMR ( Electronic Medical Records) Medical Biller and coder    examines patients records and assignes codes to diagnoses nad procedures preformed and create required docs for reimbursement from insurance, third party and patients Coders assign codes  different codeset    International Classification of Diseases (ICD) Healthcare Common Procedures Codes System (HCPCS) Current Pocedural Terminology ( CPT) Occ Therapy Aid providing services to patients who have difficulty performing work due to illness, injuries or disabilty Pharmacy Tech Performs pharmacy related functions supply prescriptions and OTC meds to customers  Physical Therapy Aid assists patients in and out of the therapy area of a clinic, offere help to patients when needed without intruding  

Insurance Coverage & Reimbursement    Health insurance, also known as heath benefits and health coverage provides patients with the means to pay the costs of medical care provided by government and private companies Public Insurance - provided by the government Private Insurance- provided by private companies Public health insurance  Medicaid, state run gov't insurance program that helps people with lower income pay for medical service Medicare, state run program for ages 65 and older Affordable Care Act (ACA) act signed in 2010 by Obama with the goal of increasing quality and affordablity of insurance Private Health Insurance Provided by employers and other organizations Three types of managed care plan HMOs-healthcare maintenance origanizations PPOs- preferred provider organizations Point of service-allows individuals to choose either HMO or PPO Deductible minimum amount a person must pay before the insurer pays any expenses to the provider Copayment predetermined amount defined by the insurer each time a service is accessed Co insurance  splitting the cost between individuals and the insurance Medicare Part A automatically enrolled, includes inpatient care, skilled nursing care, hospice care Medicar Part B covers supplies and services, can cover outpatient services,lab tests and visits, durable medical equipment, also ambulance and preventive care Medicare Part C enables beneficiaries to select a plan that includes supplemental coverage, covers prescription drugs, or choose a plan without drug coverage

Diagnoses Related Group - DRGs statiscal system of classifying any inpatient stays into groups for the purpose of payment. DRGs use a formula to calculate reimbursement for healthcare providers in an acute setting (hospitals) Principal Diagnoses-primary condition led to the patient being admitted to hospital Secondary Diagnoses-complications that may affect the patients course of treatment or prolong length of stay in hospital                     Key Points Tricare is managed by Dept of defense and provides health insurance for military personnel and family Two types of private health insurance re HMOs and PPOs Medicaid is funded by both state and federal governments serves low income families

AFFORE CARE ACT-ACA the patient protection and affordable care act healthcare and education reconciliation act of 2010 The ACA seeks to accomplish the following Increase access to healthcare protect people as healthcare consumers improve the quality of healthcare lower healthcare costs PCIP-preexisting condition insurance plan allows people with preexisting conditions such as cancer to qualify for health insurance Young adults up to age 26 are able to stay on their parents insurance Many americans who retired before age 65 without health insurance prior to 2014 fell under the early retiree insurance program Program was available to citizens age 55-65 The ACA addresses shortages of healthcare providers such as rural areas by providing scholarships, loan forgiveness programs  Insurance companies are required to explain the costs of premiums Medicaid eligibilty numbers have increased for each state IPAB-Independent Payment Advisory Board Reduce costs, eliminate waste, improve healthcare for seniors ACOs- groups of doctors doctors, hospitals and other  healthcare providers  ​​​​​​​goals are to ensure patients get right care IPABs and ACOS- how they impact medical billers coder ​​​​​​​IPABs make projections about the amount of money that will be reimbursed for hospital supplies and services . Doctors receive higher reimbursement rate treating patients who have medicaid as their primary insurance  Individuals who can afford health insurance are required to enroll states are receiving incentives to expand Medicaid coverage as a they will receive 100% funding at the feral level thru 2018 How will the ACA improve preventive health?    Healthcare providers will be reimburse based on quality of care rather than than the number of patients treated Key Points  The Affordable Act ( ACA) included 2 acts: the patient Protection and Affordable Care Act and the Healthcare and Education Reconcilation Act of 2010 ACA brought changes such as insurance for people preexisting conditions, alowing adults to stay on their parents insurance to age 26 ACA childeren cannot be denied insurance because of a preexisiting condition The ACA seeks to increase accountabilty for insurance            

Law, Ethics, and Confidentiality Law is defined as a rule of action or conduct bounded by a controlling authority. the purpose is to protect the public laws are enforced at a national level ( federal law) and state level (state law) health  care professionals are regulated through laws known a practice acts on state and/or national levels healthcare discipline define scope of practice indicate the guidelines for maintaining licensure and certification scope of practice define procedures, actions and processes that are permitted within a healthcare discipline health care professionals should not perform outside of their scope of practice  protocols  set of rules that can explain how a task or procedure should be completed  Example: medical assistant would check a patients identification 3 different way before performing a EKG Ethics the principles and standards that govern behavior and include your moral values  Bioethics Bioethics refer to the ethical implications related to research in the field of healthcare  Code of Ethics set of principles that guide an individuals practice in healthcare most codes of ethics are modified to reflect a particular discipline promote health and safety of the patient  demonstrate honesty and integrity by practicing morally within scope of practice respect the individuality of every patient HIPPA- Health Insurance Portability  and Accountability Act  was passed in 1996 to protect patient information The purpose of this federal law is to : improve the efficiency and effectiveness of healthcare delivery  protect and enhance the rights of patients  improve the quality of healthcare  HIPPA's Privacy Rule promotes privacy for individually identifiable health information thats transmitted or maintained by electronic media Examples include patient names diagnoses, and medicine HIPPA's Security Rule provides privacy of electronic protected health information that personally identifiable info stored or transmitted in electronic for Professional and Cultural  Sensitivity  Eight Professional Characteristics  obtain the knowledge, skills and attitude of your chosen discipline be committed to maintain and uphold your knowledge and skills' be devoted to serving patients  take pride in your profession and in service that you provide maintain , a professional relationship with your client or patient  be on time for work and for meeting with your client  look professional be accountable Licensure- process by which a federal state or local gov't gants an individual permission to practice in a particular occupation profession Is subjected to regualtion under the gov't authority Certifications- process in which private organization reconize individuals  for meeting certain criteria  requires an individual to take a standardized assessment Panel Joint Commission Nurses Physicians Pharmacists Risk managers clinical engineers NPSGs correct id of patients  correct medication administation infection prevention patient all prevention Infection prevention and control aims to protect those who might be vulnerable to acquiring an infection Cultural sensativity working with colleagues and patients from all different types of backgrounds Key points Indiiduals working in the healthcare field should at professionally scope of practice refers to the procedures, actions and processes that are permitted for a licensed p National Patient Safety Goals( NPSG) helps accredited organizations address area of concern regarding patient safety

Communication and Teamwork Communication can be defined as an exchange of thoughts , ideas, information, and messages  Can improve quality of healthcare, increase patient satisfaction and safety when communication healthcare professionals and patients, consider, their perspectives emotions, and stressors. healthcare workers goals are to alleviate fears and put their minds at ease                          Communication Process- 5 essential elements Message- info that you wish to communicate. Information must be accurate  Sender-person that is sending out the message Channel- method that one uses to provide the info. Including in person, verbal, such such as a phone message, or electronic, such as email. Receiver- individual who receives the message. you should relate message only to individuals who legally have the need to know information Feedback- occurs when/if the receiver and sender reverse positions Verbal Communication involves sharing information using speech Nonverbal Communication involves conveying information rough body language and actions rather than words Written Communication involves messages that make use of the written word Therapeutic Communication occurs between a healthcare worker an patient,  Clarifying- follow up open ended questions Exploring- ask more questions Focusing-  specific questions on one area Validation- helps patients feel you understand them Reflection- repeating what is said verbatim Restating -summerizing                   KEY POINTS  Communication is an exchange of thoughts, ideas, information and messages The communication process has five elements: a message, sender, channel, receiver, and written communication Three major types of communication are verbal communication nonverbal communication and written Face to Face communication is the most effective way to convey a message Telephone communication, your intonation is important Always keep a professional tone in your emails Teamwork is essential in healthcare

LAW IN ALLIED HEALTH What is Law? Law is the set of rules that govern our behavior Criminal law prohibits ans punishes certain conduct for the benefit of society, a rime is an offense against a locale,  state, or the United State Civil law concerns the private rights ans duties of individuals who live within a society. A right is an individual power, privilege,or immunity. A duty is an individual obligation Governments create laws. which means a constitution adopted by the people creates a government and gives the gov't the power to adopt laws governing the people. The government has three branches - legislative, executive and judicial Legislation- Legislators adopt laws. Statutes are legislation passed by legisltive bodies on the federal and state levels. Ordinances are legislation adopted by local legislation bodies Administrative Regulations- Laws adopted by legislative bodies require an agency to carry out the law. Ex: FDA- is an administrative agency created to carry out or enforce laws relating to that subject ,matter. Common Law- a system or law originally developed in England developed on a case by case basis from court decisions. Licensing protects the public by ensuring that such medical personnel have met certain minimum requirements. License can be revoked for misconduct, substance abuse,fraud, criminal conduct and mental incapcity  Certification- refers to a professional organization or institution representing that a certified person have passed a test, completed a course of study. Neglignce- when medical professional fail to meet a certain standard of care. They have been negligent and are liable for damages Malpractice-failure to meet the required standard of care. adding codes (upcoding) for services not performed  lower codes (downcoding) lowering the amount of reimbursement  Vicarious Liability-  When one person is held responsible for the actions of another. Ex: A phyicians are vicariously liable for the negligence of their employees. Respondeat superior " Let the master answer"   Litigation-  process for resolving disputes thru the courts Alternative Dispute Resolution- ( ADR) process for resolving disputes outside the court that may be used before of after litgation has begun. Prelitgation- disputes that happen before litigation occurs, when something has happened and a patient is unhappy. If a medical professional has reason to believe that something has happend if a patient is complaining insurance companies may require a doctor to file an incident report .   Plaintiff- ( person who is suing) Defendants( people being sued) Summons ( formal court notice that one is being sued ) Discovery- way of collecting written or oral testimony, documents, and other evidence to use at trial. Litigants- parties to a lawsuit   Settlements- settlements are offered as part of the settlement negotiations. as more evidence is collected both sides get a better sense of victory or defeat, which create motive to settle the case Types of trials- Trial finds-or determines--the facts and applies the law to the facts Jury trial---the jury is the fact finder Bench trial- no jury, the judge serves as the fact finder and weighs evidence  Burden - what the plantiffs are obligated to prove-in a civil case such as medical malpractice is a preponderence of evidence. This means the plaintiff must prove the defendant committed malpractice Beyond Reasonable Doubt- prosecutor must prove guilt to convict someone of a crime Evidence Rules Direct examination-questioning a witness by the attorney for the party who called the witness Cross examination-questioning f a witness by anyone other than the party who called the witness Hearsay- statement originally made outside of the court that is repeated in the court room and offered as truth Speculation-when a witness gives an improper opinion rather than stating what he or she saw, heard, felt, touched, or smelled Expert Opinion-knowledgeable experts an give opinion within their fields of expertise Appeals- questions to weather an error was made at a trial court level Arbitration- the parties present evidence to a impartial person who makes binding decision on the parties Mediation occurs when a neutral third person helps the parties in a dispute reach a settlement-these are not judges Facilitative Mediation- ​​​​​​​the mediatior guides e mediation process, but doesn't express opinions on the merits of each party position ​​​​​​​instead the mediator assists in reaching  mutually agreeable resolution by asking questions that bring out each person point of view ​​​​​​​Evaluative Mediation ​​​​​​​the mediator gives opinions about the merits of the case , pointing out weaknesses and may predict what a judge or jury would likely do ​​​​​​​mediation of malpractice claims is often evaluative mediation

                                                         KEY POINTS Healthcare workers interact with the law in a numbers of ways. Law is the set of rules tht govern our behavior, punish crime and define right or duty Governments create laws in the US, the gov't was created by the Constitution, which gave the govt e power to adopt laws Three levels of government-federal, state and local. Three branches of government- legislation, executive and judsicial Negligence is failure to meet an established standard of care Litigation- process for resolving disputes through the court Initial phase of litigation is discovery, next phase is trial, next phase is appeal ADR refers to methods of resolving disutes that are alternatives to litigaton

                                          MEDICAL MALPRACTICE Negligence failure to exercise the degree of care that a reasonable person would exercise under the same circumstance  a reasonable person is a prudent individual whose behavior would be considered appropriate circumstance Malpractice professional negligence difference between ordinary negligence malpractice is the standard of care required f the injuring party Duty of Care Duty to Act- A healthcare professional who provides advice or service will be held to the professional standard " res ispa loquitur-meaning the thing speaks for itself In 2012, $3.6 billion was paid out in malpractice claims Medical malpractice is among the top 10 causes of death Medical errors account for between 44,000 and 98,000 deaths annually   Failure to Inform of Diagnoses    Failing to inform patients of their condition Preventing patients from making informed decisions Consent in Emergency Doctors can perform lifesaving procedures without a patient consent Lack of Informed Consent Lack of consent is relevant to the tort of battery Negligence can arise due to failure to disclose the risks of treatments and the harmful effects of medications Errors in Treatments Choosing the wrong treatment administering treatment incorrectly administering tests improperly Abandonent Inattention to the patient care on assumig that the doctor patient relationship no longer exist   Proximate Causation refers to the link between malpractice and harm Failure to Diagnose  Failing to observe the symptoms, order relevant tests, or interpret results properly Advance Medical Directives  Healthcare directives give instructions in advance about what a patient wants to be done medically Special Rules for Minors  Minors lack the capacity to enter into contracts Some state allow minors under 14 to give consent in case of specific treatments Contributory Negligence  if a patient contributes to causing harm- barrier to someone recovering money from a case failing to follow the doctors instructions, failing to take the medication properly and failing to disclose information the doctor needs properly diagnose and treat the patient Assumption of Risk when someone voluntarily accepts a known risk, then legally an assumption of risk has occurred Good Samaritan  Statues encourage people to respond in emergencies Statutes of limitations time periods during which a lawsuit must be brought are called statutes Medical Malpractice Insurance to protect against the liability  Product Liability liability a manufacturer or distributor of an unreasonably dangerous product has for damages caused by dangerous condiiton Burde of Proof duty to prove an element of a claim in a lawsuit

Determine Medical Malpractice and Criminal Charge Defenses  Law as 2 divisions- Civil and Criminal Law  Civil Law- private individual who is the victim of wrong doing prosecutes the claim Criminal Law- the action is prosecutes  by the state Felony- any crime thats punishable by imprisonment of one year or more Misdemeanor- crime punishable by imprisonment for less than one year   Crimes against a person ( murder and assault) Crimes against property( theft) crimes against habitation ( Burglary) Sexual Crimes ( Rape) Crimes against morality and decency ( prostitution) Crimes against government ( perjury) Criminal laws are often punish not only the act also the state of mind    "Actus reus" guilty act or the criminal act "Mens reus" guilty mind, referring to the state of mind associated with the criminal act Intentional torts- in suing for tort, the victim is seeking money to compensate for damages caused Battery-    harmful touching of another person without consent Medicare and Medicaid Anti Fraud and Abuse Amendments contain provisions making it illegal to receive payment      

                                                                                         Medical Ethics Ethics- The concept of ethics originated in ancient Greece. The word ethics comes from the Greek word, ethos, which means customs or usage. Ethical study is related to philosophy, the pursuit of wisdom. Ethical theories attempt to systemize, defend, and recommend concepts of right and wrong behavior. Ethics is about behavior. It’s also related to the law. Metaethics One of the oldest theories of ethics is metaethics. Metaethics is a branch of ethical theory that considers the origin and meaning of ethical principles. Eternal Law One view is that ethical principles exist independently of what people might choose to believe. These principles can be characterized as a kind of “eternal law” inherent in the nature of the universe.  Normative Ethics Normative ethics is another branch in the study of ethics, which involves determining the moral standards that regulate right and wrong conduct. Three theories of Normative Ethics ​​​​​​​Virtue ​​​​​​​pertains to the character of a person as displayed by the virtues that he or she possesses. Virtue theory seeks to identify virtues or character traits people should cultivate.  Consequentialist ​​​​​​​indicates that an action is morally right if the consequences of that action are more favorable than unfavorable.  Duty ​​​​​​​ pertains to a person’s obligations from the standpoint of morality. Duty theory seeks to identify duties that healthcare professionals are obligated to perform Eiquette is the proper form of social interaction in a given culture or community   Key Points Ethical theories attempt to systemize, defend and recommend concepts of right and wrong behavior Metaethics is a branch of ethical theory that considers the origin ans meaning of ethical principles Normative ethics involves determining the moral standards that regulate and wrong conduct Theories related to normative ethics are virtue theory, duty theory, and consequentialist theory The hippocratic oath is taken by physician and pertains to the ethical practice of medicine Organizations for medical coders and billers have a code of ethics that outlines principles governing the moral and ethical conduct of all members Etiquette is the proper form of social interaction Professional etiquette is important to patient satisfaction The first known book of etiquette, attributed Egyptian official PtahHotep, dates to the 24th century B.C.E. In 1922

Contemporary Medical Ethical Issues Formulary list approved drugs fro which doctors must prescribe to have insurance cover the pharmacicals Global Comparision most industrial societies have universal health system that provide healthcare to all citizens and permit them to freely choose their doctors and hospitals Insurance Appeal patents who believe that their insurers have wrongfully denied healthcare services, treatments or procedures or have delayed the referral process may have the right to appeal those insurance company actions Medical Tourism practice of traveling to other countries for medical procedures because of lower costs Concern for a pandemic epidemic or sudden outbreak that becomes widespread. Scientist have become concerned of possibilty  Nuremburg Code  drafted after WW2 because of Nazi experiments on prisoners in concentration camps. It forbids performing medical experiments on humans without their consent US Experiments    In the US, several instances of medical experimentation on humans have occurred. patients suffering from syphilis werent given treatment so the course of the disease could be studied  EFIC ( Exception for Informed Consent In 1996, the FDA adopted the EFIC permitting emergency research without patient consent under certain conditons. ​​​​​​​allows potentially life saving research to be carried out in emergency situations . Requirements: there is a life threatening medical condition for which treatment are unproven prior consent isnt feasible direct benefit to subjects is anticipated research risks are minimal given the patient life threatening circumstances  research couldnt be conducted within the theraputic window  

                                                              Medical Paternalism and Autonomy Patient Autonomy requires that patient give informed consent before the start of any medical treatment Medical Paternalism takes this power away from patients as gives it to medical personnel or the government Exceptions  to informed consent involve emergencies when a patient--or someone on the patients behalf--is unable to consent Generally, most states hold that competent adults have the right to refuse medical care. Adults patients who believe medical treatment violate their religious beliefs may reuse such treatment Parents and guardians are generally authorized to make medical decisions for minors. if  minor is in critical condition and the parents refuse the courts will order treatment Aa healthcare provider who cant accept  a patient wished to forego treatment find other alternative health providers who can provide care   OPTN-Organ Procurement and Transplant Network operated by the nonprofit United Network for Organ Sharing (UNOS) composed of transplant physicians, government officials, immunology specialists The NATIONAL ORGAN TRANSPLANT ACT OF 1984, established the OPTN, a national system to address fair allocation of organs for transplant Uniform Anatomical Gift Act, which authorizes gifts of the body or any part of the body ​​​​​​​donor must be at least 18 the gift is revocable during the donor lifetime and it becomes effective on death if no gift has been made, then relatives in a stated order of priority have the right to make the gift recipients of the gift re limited to certain medical personnel or institutions purpose of the gift a restricted to transplantation therapy research educationand the advancement of medical or dental science  The ethical treatment of individuals with AIDS/HIV is controversial to some due to how the conditions first appeared in the US The Needlestick Safety ans Prevention Act was adopted to increase safety of needle use by healthcare worker in response to concern about contracting HIV from infected patient

Ethics and Reproductive Health Nonnatural Conception extent to which science can manipulate the beginning of life grows every day. Test tube fertilization and artificial insemination are non natural methods of conceptions Eugenics science that deals with improving hereditary qualities ​​​​​​​negative eugenics limits or discourages reproduction by those considered genetically inferior Genetics Diseases ​​​​​​​human genetics diseases many are linked to a defect in a single gene. Testing for genetic information is fairly simple, can lead to better treatment and prevention Fetus Rights ​​​​​​​Amniocentesis a medical technique used to test DNA in amniotic fluid , allows physicians to identify genetic abnormalities Fetal Homicide ​​​​​​​fetal homicide laws, which make using the death of a fetus a crime separate and independent from any crime committed against  women carrying the fetus Wrongful Life ​​​​​​​child born with  a painful congenital deformity that was detectable but wasnt detected or disclosed while abortion was an option can sue a doctor for the pain that could have been avoided Wrongful Birth ​​​​​​​parent caims against doctor for damages caused by the birth of a child that occur when a doctor fails to disclose and detect a child birth defect Miftpristone- steriod used to terminate pregency before 7th week

Recognize Ethical End of Life Issues Advance medical directives Advance medical directives are instructions people may give regarding their wishes concerning medical treatment in the event that they’re unable to make those decisions for themselves. Living Wills A living will expresses a patient’s wishes regarding care in the event of a terminal condition. Medical providers can use this to understand whether the patient would forego extraordinary treatment in the event of a terminal condition or persistent vegetative state Durable Power of Attorney ​​​​​​​A Durable Power of Attorney, or DPA, authorizes a person to make medical decisions for a patient when that patient is unable to do so. A DPA can also include instructions on medical treatment the patient wants and doesn’t want. Patient Right to Die ​​​​​​​Cruzan v. Director, Missouri Department of Health, was an important decision on the issue of a patient’s right to die a natural death. Nancy Cruzan’s parents filed a suit to remove life support from their daughter, who was in a persistent vegetative state. Patient Self Determination Act ​​​​​​​The Patient Self-Determination Act, or PSDA, of 1991 requires hospitals that receive Medicare and Medicaid funds (which includes most hospitals) to provide written information to each patient concerning patients’ rights under state law to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives​​​​​​​ Assisted Suicide Assisted suicide occurs when a patient takes actions to terminate his or her life using means supplied by someone else. I Euthanasia ​​​​​​​when a person takes an action that causes the death of another person It is illegal in the US  Belgium Luxemburg Netherlands permit euthanasia under narrow circumstances Do Not Resscitate DNR ​​​​​​​orders prevent efforts to resuscitate those who have exhibited signs of death

                                                                     Confidentiality  in Allied Health Health Information and the Courts Medical records serves two important functions ​​​​​​​providing information for patients care and evidence in malpractice suits Medical records are records that systematically documents a patient medical history , treatment and care, Medical Records as patient history ​​​​​​​patients medical history  patients reports ans medications details for overall care Medical records as legal evidence  ​​​​​​​Documentary evidence - papers ans documents such as medical records Testimonial evidence-witness statements Real evidence--tangible things such as scalpel Demonstrative evidence--things that help illustrate a testimony, such as a chart  ray recording or model The Concepts Governing Rules of Admissible Evidence  ​​​​​​​Relevance  ​​​​​​​evidence is relevant if it tends or disprove an issue significant to the case Irrelevant evidence may be objected by the opposing attorney Competence  ​​​​​​​refers to the evidence the court should accept as proof Testimony evidence is competent wen ​​​​​​​witnesses understand the duty to tell the truth and take an oath to speak truthfully A doctor considered an expert witness and may give a personal opinion Hearsay ​​​​​​​considered secondhand evidence in which witnesses arent telling what they know personally rather what others have said to them. It can be oral or writen ​​​​​​​The requirements for the exception ​​​​​​​there must be evidence that the records were made during business hours at or near the tie by the person with knowledge of the information records must be accurate and trustworthy this may require additonal testimony Doctor patient priviliege ​​​​​​​represents a relationship in which a patient medical history , conditions and related information cant be made known without that patient permission When a patient doesnt give such authorization, legal counsel should be consulted regarding weather privilege should be asserted Court Orders  ​​​​​​​to release medical records are used when releasing the information without such an order would violate statutes or regulation Under the HIPPA protected health info may be disclosed in a judicial or administrative proceeding if the request for the info is made thru a order of the court Subpeaona ​​​​​​​commands issued by the court may be a subpoena ad testificandum, which commands  witness to appear and give testimony subpoena duces tecum- commands a witness to produce documents or things or both, used to compel the release of medical records Precautions of answering  a subpoena ​​​​​​​determine if the subpoena issued in the jurisdiction also require written consent fro the patient determine if the info requested involves treatment for substance abuse, mental health, AIDS, or other special types information refer questionable requests to counsel for advice on how to respond Limitation on disclourse ​​​​​​​a valid court order identifies e court issuing the order  the parties to the case the case number and limitations on disclosure                            Key Points Medical records provide information essential to the proper care of patients, they contain evidence that may be used when  patient condition or doctor treatment is involoved in a legal case Admissible evidence that can be used at a trial includes testionial documentary and real evidence evidence should be relevant to the case( able to prove or disprove a significant  issue) and compentnt Hearsay is evidence in which witnesses arent telling what they know personally but they are relaying what other should accept as proof Doctor patient privilege represents a relationship in which a patient medical history conditions and related information cant be made known without that paitent permission

Creating and Maintaining Medical Records Clinical Uses information that caregivers case in diagnosing and treating medical problems. they also offer a way for medical providers to exchange information about patients Non Clinical Uses medical records may include information that may relate to third parties who have a financial interest in a patient medical condition also can involve the potential commercial use of the information they contain Rules concerning medical records can approached from three perspectives the content of the record, retaining the record securely, and the destruction of the record Statuatory/Regulatory requirements pertaining to medical care and payment for medical care may require the creation and maintenance of certain records Accrediting Standards organization such as ( JCAHO) Joint Commission on Accreditation of Healthcare Organizations have accredited standards that address medical records.    ​​​​​​​other organization such as AAPC/AHIMA- provide ethical and professional standard for employees in health information management such a medical coders Institutional Standards ​​​​​​​have their own standards and procedures that apply to medical records Authentication ​​​​​​​is the confirmation of the content of an entry in a medical record. It acts as verification of the accuracy of information. It must be reformed by the person who creates the data The authentication requirement is essential to establish the business records hearsay exception. A necessary part of the foundation for the business records exception is that the record was created by a person with firsthand knowledge of what being recorded AHIMA- recommends keeping medical records for 10 years Some states may have laws that require medical records to be preserved for a certain period of time Medical records should be kept 7-10 years after date of last treatment Minors present a special problem because the statute limit ations doesnt begin to run out until adulthood

  Creating and Maintaining Medical Records Medical Records must be authentic. The author of a medical record is the medical provider who has created the data that appear in the record. Authentication is the confirmation of the content of an entry in a medical record. It acts as verification of the accuracy of the information. An entry can be authenticated with a signature or initial. What happens if a healthcare provider disagrees with a correction? if a healthcare provider doesnt want to make a change requested by the patient, the patient is entitled to a written notice of the doctor decision. According to HIPPA, the patient have the right to errors corrected in their medical records AHIMA recommends keeping record for 10 years Medical records should be kept for 7 to 10 years after the date of last treatment MInors present a special problem, statute of limitation doesnt begin until adulthood Destruction of Medical Records method used for destruction of physical records , shredding or burning, some laws require that the owner of the records create an abstract of the patient data before destroying them abstract- summary of essential points Many healthcare providers contract out records destruction to a third party, the healthcare provider is still responsible to ensure the proper method and safeguards are used for privacy A dated certificate of destruction should document that record were properly destroyed. this is important should government agencies raise a question about missing records If a medical practice goes out of business ​​​​​​​records might have to be transferred to another healthcare agency for storage and notice to the licensing agency may be required  Key Points Medical record is a document that includes a patient history condition diagnostic and therapeutic treatment and results of treatment. Medical records are a repository of information that caregivers can use in diagnosing and treat medical problem Rules concerning medical records can be approached from three perspectives ​​​​​​​the content of the record retaining the record securely and the destruction of the record                                                                             

Confidentiality and Government Medical Records The AMA's coded of ethics states that physician may not disclose information revealed by a patient or discovered by the physician in connection with the treatment of a patient According to the  AMA's council on Ethical and Judicial affairs the purpose of the physician ethical duty to maintain patient confidentailty is allow the patient to feel free to make a full and frank disclosure of information to the physician Consequences ​​​​​​​maintaining patient confidentality is a legal duty  as well as an ethical duty. Courts generally allow a cause of action for breach of confidentiality against a treating physician who divulges confidential medical information without proper authorization the patient The legal basis for confidentality is the right of privacy derived from the Constitution, statutes and the common law Doctor Patient Privilege ​​​​​​​obligation of physicians not to testify about statements made to them by their patients. Informed Consent  ​​​​​​​process of communication between a doctor and a patient in which the doctor explains the factors involved  a recommended medical process The Freedom of Information Act (FOIA) is a federal law intended to provide access to government records. ​​​​​​​Basically, these acts create access to government records but also create exceptions to safeguard medical information Another Federal law, the Privacy Act of 1974, prohibits disclosure of certain medical information by government agencies unless the patient gives written consent Some government, such as the Social Security Administration and the Department of Heath and Human Services, release data they've collected for purposes of research                                                                               Key Points   

Apply Privacy Rules to Patient Information Patients dont own their medical record. Healthcare provisers create medical  records and therefore hem. HIPPA gives patients the right to access their healthcare information and determine who else may have access Regulations in HIPPA apply to three groups of individual and corporate entities know as covered entities  Healthcare providers persons, businesses and entities that furnish, bill or receive payment for healthcare in the ordinary course of business and transmit any of these transactions electronically Health plans any individuals or groups at provide or pay the cost of medical care, including public and private health insurance issuers, employee benefit plans  Medicare ,Medicaid Healthcare clearing houses ​​​​​​​public or private entities that either process or facilitate the processing of health information HIPPA privacy rules gives individuals a fundamental new right to be informed of the privacy practices of their health plans Health plans and covered health care providers are required to develop and distribute a notice that provides a explaination of these rights    A notice of use and disclosure must contain the following: The way in which the covered enitity may use and disclose protected health information about an individual The individual right with respect to the information and how the individual may exercise these rights, including how the individual may complain to the covered entity The covered entity legal duties with respect to the information, including statement that the covered entity is required by law to maintain the privacy of protected health information Whom individuals can contact for further information about the covered entiity privacy policies According to HIPPA, protected health information ( PHI), includes any individually identifiable health information.  De identifiable information ( information that is stripped of data that may identify an individual. isnt covered under the privacy rule. A limited data set is middle ground between identifiable and de-identifiable information. In a limited data set most identifying information has been removed . The following identifiers may be included as part of a limited data set ​​​​​​​Geographic data ( town city state ZIP code Dates relating to an individual( birth date admission and discharge dates) Unique ID numbers characteristics or codes other than those listed  A covered entity use or disclose PHI for treatment, payment, and healthcare operations Treatment ​​​​​​​means the provision coordinaton or management of healthcare and related services by one or more healthcare providers Payment ​​​​​​​payment encompasses the activities of healthcare providers to obtain payment or be reimbursed for their services  and the activities of a health plan to obtain premiums, Healthcare Operations ​​​​​​​certain administrative, financial, legal, and quality improvement activities of a covered entitiy that are necessary to run its business and to support the cored functions of treatment and payment The Privacy Rule allows covered entities to use or disclose PHI without first obtaining a patient consent for the following purposes ​​​​​​​For its own treatment, payment and health operations activities For the treatment activities of a healthcare provider  For use by another covered entity or health care provider ( including providers covered by the Privacy Rule) for the payment activities of the entiity that receives the information For certain healthcare operations of the entity that receives the information For any healthcare operations or an organized healthcare arrangement of another covered entity that participates in organized healthcare arrangement A covered entity should release only the minimum necessary health informaton needed to accomplish the purpose of the disclosure Valid authorization includes 

Requirements for Authorization to Disclose Valid authorization includes description of information who is requesting the information why the information is being requested expiration date signature of the individual authorization date Individuals have a right to revoke authorization for the release of their health records in writing Revoking may affect medical treatment payment for services  eligibility for benefits Parents  are personal representatives  can exercise patient rights cant access some records Covered entities ​​​​​​​state  territory political subdivission native american tribe entiity acting under authority Protected health information can be given to covered entities without authorization for the purpose of preventing or controlling disease injury and disability Limitations to disclosure ​​​​​​​​​​​​​​Disclosure without authorization ​​​​​​​child abuse or neglect FDA needs to collect or report information At risk for contracting or spreading disease Work related injury (OSHA) Billing purposes HIPPA authorization Release to researchers​​​​​​​ ​​​​​​​patient authorized limited data set approved by IRB establish research protocol Deceased patient The Privacy Rule provides special rules regarding psychotherapy noted that limit use or disclosure with out consent

Occupational Safety Health Administration ( OSHA) OSHA is responsible for enforcing safety rules in the workplace OSHA was created Congress under the Occupational Safety and Health Act of 1970, and is part of the Department of Labor Worker have the right to be protected from situations at work that are known to be potentially able to cause injury or death. Employers have a responsibilty to provide a safe hazard free working environment The OSHA ACT covers employees in the private sector and many employees in the public sector Covers all 50 states There are 2 levels of OSHA jurisdication-state and federal Workers who are self employed or who work on a farm owned by an immediate family member are not covered under OSHA Federal agency such as Federal Aviation Administration or the Coast Guard are not covered   Examples of OSHA include  protecting workers from falls preventing exposure to infectious diseases ensuring that workers safely enter confined areas  preventing exposure to harmful substances such as abestos supplying safety equipment  providing training for dangerous jobs Based on standards established by OSHA, workers have the right to: ​​​​​​​ask OSHA to inspect their work area to make sure its free from potential dangers access the results of any tests designed to pinpoint dangers in the workplace Review information about OSHA and workplace hazards in clear language that they can understand See records of injuries and illnesses that occured in the workplace  Get copies of their own medical records Exercise the above rights to a danger free workplace without fear of retailiation or discrimination OSHA has a separate form for whistleblower  ​​​​​​​A whistleblower is employee who informs OSHA of illegal activity OSHA is responsible for protecting whistleblower under 21 different federal statutes including laws to applying to: ​​​​​​​environmental and nuclear safety transportation consumer products A person has 30 60 90 or 180 days to file  a complaint

Special Types of Health Information Adoptions records are confidential the information therein generally cant be disclosed or disclosure is limited to very specific information. Court order or litigation may be necessary to authorize release In reference adoptees, refers to any data that may lead to the positive identification of an adopted person, the birth parent or other birth relatives If consent isnt on file the information may not be released without a court order documenting good cause to release the information A mutual consent registry is one method many states use to arrange the consents required for the release of identifying information related to adoptions. a minimal consent registry is a system whereby individuals directly involved in adoptions can indicate their willingness or unwillingness to have their identifying information disclosed search and consent procedures-authorize a public or private agency to assist a party in locating birth family members to determine if they consent to the release of information confidentiality intermediary system-a person is certified by a court as a confidential intermediary, which allows him or her to have access to sealed adoption records for the purpose  Substance Abuse ​​​​​​​refers to the excessive use ( or abuse) of alcohol or drugs. Information related  to the treatment of persons for substance abuse Two federal laws are important in the area of releasing information related to substance abuse ​​​​​​​ Drug Abuse Prevention Treatment and Rehabilitation Act The Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabilitation Act of 1970 If the patient authorizes disclosure, the disclosure must be in writing  and it must contain  ​​​​​​​name of patient  name of program information to be disclosed  name of person or facility to which the information is disclosed  the purpose  the disclosure Dated signature of patient ,parent or guardian, or the signature of a person authorized to sign on behalf of patient  statement that the consent is subject revocation at any time Date, event or condition that will terminate Mental Heath ​​​​​​​the medical records maintained by a psychiatirc hospital must permits determination of the degree and intensity of the treatment provided  to individuals who are furnished services in the institution Psychiatric evaluation ​​​​​​​be completed within 60 hours of admission include a medical history  contain a record of mental status note the onset of illness and the circumstance leading to admission describe attitude and behavior Treatment ​​​​​​​each patient must have individual comprehensive treatment plan . The written plan must include ​​​​​​​a sustained diagnoses  short term and long range goals specific treatment modalities utilized   

HIV Information The virus responsible for AIDS is transmitted in four common ways High risk sexual contact Intravenous drug use Transmission from mother to child around the time of birth Blood transfusions and other known causes HIV tests for antibodies can be performed on blood ( the most common method) Enzyme Immunoassay ( EIA) used on blood drawn from a vein, is the most common screening test used to look for HIV antibodies. An EIA test shows a positive will be followed by tests to confirm those results Human immunodeficiency virus ( HIV) suppresses individuals immune systems, making them more vulnerable to other diseases. It may eventually develop into acquired syndrome The CDC serves as the national ocus for developing and applying disease prevention and control,environment health and education activities designed to improve the health of the people Many people who have been infected by HOV have few symptoms therefore testing may be the only way to know weather a patient is infected The CDC recommends HIV testing for all patients between 13 and 64 years old   

Management of Risk, Quality and Electronic Medical Records Risk management identifies areas of risk to medical service providers Risk management is used in many professions and services. The Joint Commission on Accreditation Health care  Organizations ( JCAHO) requires hospital to implement risk management programs.  Lost Prevention is a planned systematic and proactive process.  Loss reduction involves the steps taken after an event or incident occurs. Process for treating patient -risk management  Confidentiality must not be compromised by providing access to those  who arent qualified to access the records Easy access for purpose of medical treatment is necessary to promptly and correctly treat a patient Records must be secure against alteration or destruction Records must be retained for a period no less than the statute of limitations or otherwise required by law HIPPA also requires that healthcare facilities keep the following information for six years records of privacy policy practices and procedures the facility privacy practices notices records of disposition of complaints about compliance with the final privacy rule Other similiar types of information Incidents that require reporting are defined in the procedures manuals for healthcare facilities. Incidents not only mistakes in providing care, but also things such as patient injuries unrelated to care, such as falls An incident report serves two general purposes . one relates  risk management as such-documenting  the incident and spotting potential litigation problems Quality management is controlled by peer review committees. These committeess consists of health professionals who monitor the quality and use of healthcare services. A typical method of doing so is through an audit and review of patient information The National Practitioner Data Bank was created for two purposes, first to improve the quality of healthcare by encouraging state licensing boards, hospitals, other healthcare entities and professional socities to identify and discipline those who engagse in unprofessional behavior and second to restrict the ability of incompetent physicians, dentists. Information required to be reported to the NPDB Medical malpractice payments each entity that makes a medical malpractice payment for the benefit of a physician dentist or other healthcare must report certain payment information to the NPDB Adverse licensure actions ​​​​​​​state medical and dental boards must report certain displinary actions related to professional competence or conduct taken against the license or physicians or dentist Adverse Clinical Privileges  ​​​​​​​Mandatory reporting. Hospitals and other eligible healthcare entities  must report professional review actions that adversely affect a physician dentist clinical privilege  for a period of 30 days Adverse Professional Membership ​​​​​​​professional must report specific information when any professional review action, based on reasons related to professional competence or conduct A query is a request for information submitted to the NPDB by an eligible entity or authorized agent. ​​​​​​​​​​​​​​Mandatory Querying ​​​​​​​Hospitals must query the NPDB in accordance with the following ​​​​​​​When a doctor applies for privileges  Every 2 years for doctors on the medical staff or those holding privileges. When a practitioner wishes to as or expand existing privileges When a practitioner submits an application for temporary privileges  

Risk and Quality Management of Electronic Information Scanning papers saves sapce and money Special laws now govern digital imaging of health records Potential Benefits of Electronic Medical Records    Instant access to a patients complete health records Medical history Treatment Lab results Drug allergies Retrieval of abstract of information through assigning codes for necessary treatment  for support in additonal healthcare services    H-I-P-A-A, also known as HIPAA, has created national standards for submitting all electronic healthcare transactions to any health plan in the United States—and the health plan must accept it. These standards aim to make electronic data interchange, or EDI, a viable and preferable alternative to paper processing for both healthcare providers and health plans and typically supersede any conflicting state law. The HIPAA national standards apply to any EDI. Information stored in other formats must be translated into the standard formats prior to electronic transmission. In addition to federal and state law, the standards of licensing authorities and accrediting agencies may apply. Some states have legislated specifically regarding the practice of creating and storing medical information electronically. Where HIPAA rules conflict with state law, federal law and regulations preempt the conflicting state rules. You’ll now learn about some considerations related to the use of electronic medical records. These include the following: • Authentication of Electronic Records • Biometric Identification • Admissibility of Electronic Records • Secure Access T        

Risk and Quality Management Electronic Records ( cont) For records created electronically, a coded computer-generated signature can authenticate entry. Coded computer-generated signatures, passcodes, or passwords help establish the identity of personnel making or modifying entries. Biometrics refers to technologies that identify people through fingerprints, retinal patterns, and voice patterns.     Biometrics can be used to identify a patient and simplify secure access to records. Fingerprints can identify a patient who is physically present; voice recognition software can help verify the identity of a patient over the phone. This prevents health identity fraud. The reliable authentication process of biometrics isn’t subject to the reliance on remembering a specific password or the potential abuse that password sharing allows. Medical records can be used as evidence in any court case in which the physical or mental condition of a person is at issue. Admissibility of medical records is a key issue, as they might be objectionable as hearsay. A medical record consists of statements by doctors, nurses, and other healthcare professionals.   If a medical record can’t be introduced in a case, everyone who made entries into the record would have to be called as witnesses to testify. Those involved in the case need to answer a few key questions to prove the validity of the medical records submitted as evidence. To answer these questions and avoid an objection based on hearsay, courts may use the business records exception. For a record to comply with this exception, there must be evidence that it was made in the ordinary course of business, at or near the time the event occurred, and it must have been made by a person with knowledge of the information in the record.   The Medicare Conditions of Participation, the standards of the Joint Commission on Accreditation of Healthcare Organizations, and most state licensing laws also have rules regarding security. The issues with electronic information are basically the same as those with paper records:   Who should have access? • Security breaches of medical records can be reduced by: • Using good passwords, changing them frequently, and not sharing them • Using biometrics instead of passwords • Creating different levels of access based on the need to know • Training employees in safe practices, such as logging off immediately after access • Installing appropriate software to guard against hacking, spyware, viruses, and so on • Backing up files Storage of data, whether by a healthcare facility or a third party, must also be secure and in compliance with all HIPAA rules.  Key Points Two methods used to avoid discovery : attorney client privlege and the work product doctrine The NPDB requires information to be reported regarding the practitioner, including malpractice payments, adverse licensure actions Electronic Medical Records provide instant access to a person complete health records. HIPPA has created national standards for all electronic healthcare transactions