medical law and ethics lesson 3: documentation and regulations
TRANSCRIPT
Medical Law and EthicsMedical Law and EthicsLesson 3:Lesson 3:Documentation and RegulationsDocumentation and Regulations
Lesson ObjectivesLesson ObjectivesLesson 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.
DocumentationDocumentation
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 Information Documented in a Patient’s ChartPatient’s Chart
Calls and visitsTreatmentsNo-showsAppointment
cancellationsMedicationsPrescription
refillsVital signsOther pertinent
information
Cautions with DocumentationCautions with DocumentationBe careful with fax transmissions
of medical recordsReceiving fax must be located in
a restricted areaA disclaimer should be placed on
the fax cover explaining that records are confidential
Court TestimonyCourt TestimonyIf 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 ProvideReports Physicians Must Provide
BirthsStillbirthsDeathsCommunicable illnesses or diseasesDrug abuseCertain injuriesAbuse of child and adultsGunshot and knife woundsAnimal bites
Mandated ReporterMandated ReporterMust report abuse or risk fines
and/or jail time
Child AbuseChild Abuse
Physicians have a duty to report questionable injuries of children
Requirements differ by state
These injuries include:◦ Bruises◦ Fractured bones◦ Burns◦ Malnutrition◦ Poor growth◦ Lack of hygiene
Elder AbuseElder AbusePhysicians have a duty to report
questionable injuries of the elderly
These requirements include:◦Physical abuse◦Neglect◦Abandonment
Requirements differ by state
Drug AbuseDrug Abuse
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 224Form DEA 224Used by physicians to register
with the DEAAllows physicians to prescribe,
dispense, or administer controlled substances
Renewal is required every 3 years
Requirements for Controlled Requirements for Controlled SubstancesSubstancesControlled drugs must be kept in
a double-locked cabinetAny theft must be immediately
reportedPhysician’s black bag and
prescription blanks should always be stored in a secure, locked location
Schedule for Controlled Schedule for Controlled SubstancesSubstancesSchedule I (cocaine, LSD)
◦ Highest potential for addiction and abuseSchedule II (Morphine)
◦ High potential for addiction and abuseSchedule III (anabolic steroids)
◦ Moderate to low potential for addiction and abuse
Schedule IV (valium)◦ Lower potential than Schedule III drugs
Schedule V (tylenol w/codeine)◦ Low potential for addiction and abuse
Role of the Medical AssistantRole of the Medical AssistantDoes not dispense controlled
substancesMust be knowledgeable about
the regulations of the drugsOnly licensed personnel are
permitted to dispense drugsAlways report any unusual
patient behavior indicating addictive drug use
If you are aware of illegal activity and remain silent, you may be liable.
MA’s Role Related to MA’s Role Related to Confidentiality/Privacy IssuesConfidentiality/Privacy IssuesNever 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
MA’s Role Related to MA’s Role Related to Confidentiality/Privacy IssuesConfidentiality/Privacy Issues
Never discuss anything about the patient outside of the office
Make sure that a female MA is present when the physician (male or female) examines a female patient
Treat all patients with dignity and respect
MA’s Role Related to Office MA’s Role Related to Office ManagementManagement
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 MA’s Role Related to Office ManagementManagementNever 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
Medical documents are legal documents and may be used in a court of law.
MA’s Role Related to MA’s Role Related to DocumentationDocumentationCarefully sign or initial every notedocument the no-show’sDocument referrals to another
physicianFollow up to make sure the patient did
see the referral physician
MA’s Role Related to MA’s Role Related to DocumentationDocumentation
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
MA’s Role Related to MA’s Role Related to DocumentationDocumentation
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
MA’s Role Related to Drug MA’s Role Related to Drug RegulationsRegulations
May administer medication only under the direct supervision of a physician
Follow the Controlled Substances Act
Know state lawsSecure the supply of
prescription pads from theft at all times
MA’s Role Related to Drug MA’s Role Related to Drug RegulationsRegulations
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
Continue your education and training to maintain
your skill levels.
MA’s Role Related to Certification MA’s Role Related to Certification and Licensingand 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
File signed informed consents immediately!
MA’s Role Related to Informed MA’s Role Related to Informed ConsentConsent 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
If you knowingly overlook a hazard you could be found guilty of negligence!
MA’s Role Related to Safety IssuesMA’s Role Related to Safety Issues
Maintain a safe environment
Report any safety hazards at once
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Medical Ethics