Study Guide Cards (H&R)

What are the four elements that must be present in order to have successful medical neglect suit

Duty

Breach of Duty

Causation

Injury/Damages

Who has the burden of proof in a malpractice suit

plaintiff

plaintiff

the one bringing the complaint

What duty needs to be proven in medical malpractice suit

patient/client relationship

scope of practice

level of care that would be provided by a reasonably prudent clinician under similar circumstances

Doctrine of “res ipsa loquitor”

(“thing speaks for itself”)

Legal doctrine based on the premise that the negligence is so obvious that the patient’s injury “speaks for itself”

Expert witnesses usually not needed

When is “res ipsa loquitor” helpful

a conspiracy of silence

What are the types of breach of duty for malpractice

Acts of Omission

Acts of Commission

Act of Omission

failed to do something he/she should have done

Act of Commission

done something that he/she should not have done

What establishes standard of care for malpractice suits

Expert testimony

Practice guidelines

Textbooks

Statutes

Regulation

What satsifies the “causation” element in a malpractice suit

Proof that the breach of duty caused the bad outcome experience

What element of malpractice is generally the hardest to prove

Causation

What can be awarded in a successful malpractice suit

• Medical costs

• Lifetime loss of wages (predicted)

• Pain and suffering

• Loss of consortium (non-economic damages)

• Punitive damages (in egregious cases)

Statutes of Limitations

a limit on time for initiating a malpractice claim which varies by state

What is the medical malpractice statute of limitations for PA

For adults, either

• 2 years from the time he/she knew or reasonably should have known that they were a victim

• At least by 7 years

For minors,

• 7 years after they turn 20 y/o

What is the only case in which the 7 years from the time of malpractice statue of limitation does not apply

An object being left in the body

(T/F) All providers need to have malpractice insurance

True

What is the PA requirement for malpractice insurance

$1,000,000 per claim

$3,000,000 in aggregate

MCARE

A PA state fund that covered excess losses in malpractice suits

Who do PAs get their malpractice insurance through?

Employer

Types of Malpractice Insurance

Occurence

Claims Made

Occurence Malpractice Insurance

Insurance that covers anyhting that occurs while insurance is in force, regardless to when the claim is filed

Claims Made Malpractice Insurance

Insurance that only covers claims made while the insurance is acive

Tail Coverage (Insurance)

A type of malpractice insurance used after claims made to cover claims that get filed after the insurance lapses

EMTALA (Emergency Medical Treatment and Active Labor Act)

A 1986 law that states that any patient in an emergency department must recieve non-discriminatory screening, stabilization, and/or transfer

What is the purpose of EMTALA

Ensures public access to emergency services regardless of ability to pay

JCAHO

An independent non-profit organization that Accredits and certifies healthcare organizations

What is JCAHO’s mission

To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value

What is JCAHO’s vision

All people always experience the safest, highest quality, best-value health care across all setting

Hospitals must show adherence to standards from what organization

JCAHO

What are the types of “events” that can occur

Near Miss

Incident

Serious Event

Infrastructure Failure

Near Miss Event

Event that could have happened but was stopped before reaching the patient

What type of event is Medication/diagnostic test ordered on the wrong patient

Near Miss

What type of event is Lab Specimen with another patient’s label

Near Miss

What type of event is Scheduling of the wrong extremity

Near Miss

incident

An event involving the clinical care of a patient which could have injured the patient but did not cause an unanticipated injury or require the delivery of additional health service

What type of event is Patient fall without injury

incident

What type of event is Patient provided Percocet instead of Oxycodone

incident

What type of event is Patient had a CT scan of the abdomen and pelvis; only ordered abdomen.

Incident

Serious Event

An event involving the clinical care of a patient that results in death or compromises patient safety and results in unanticipated injury requiring the delivery of additional health care services to the patient

What type of event is Patient requiring treatment due to medication error

Serious Event

What type of event is Surgical Site Infection

Serious Event

What type of event is Fall with fracture requiring surgical repair

Serious Event

What type of event is Retained surgical items

Serious Event

What type of event is Pneumothorax after central line placement

Serious Event

What type of event is Stroke/MI during admission

Serious Event

What type of event is Return to OR for bleeding

Serious Event

What type of event is Pressure Injuries

Serious Event

Infrastructure failure

An undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient safety

What type of event is Power failure resulting in moving patients

Infrastructure failure

What type of event is Emergency Department Diverts

Infrastructure failure

What type of event is Elopements

Infrastructure failure

What type of event is Suicide Attempts

Infrastructure failure

Stress

a physical, mental, or emotional factor that causes bodily or mental tension.

How does the body react to stress

• Catecholamine hormones, adrenaline or noradrenaline, facilitate immediate physical reactions.

• Breathing becomes more rapid

• Digestive system slows down

• Heart rate rises

• Immune system goes down

• Muscles become tense

• We do not sleep

Burnout

State of mental and/or physical exhaustion caused by excessive and prolonged stress

What are signs of burnout

Irritability

Lack of motivation

Loss of creativity

Depersonalization

Loss of sense of accomplishment

negative attitude toward his or her job,

low self-esteem,

personal devaluation.

Principal Diagnosis

condition which, after study, precipitated the patient’s admission to the hospital.

What drives the DRG assignment

Prinicpial Diagnosis

What needs to be align for a provider to be paid

Correct CPT code for medically necessary service

Correct ICD-10 code to support CPT code

Service is covered by patient’s policy / contract

How should symptoms be diagnosed

symptom due to (Principial dx)

Secondary diagnoses

Any other diagnosis, other than principial, that meets the following:

• Clinical Evaluation

• Therapeutic Treatment

• Diagnositc Studies

• Extended Length of stary

• Increased nursing care and/or montiorng

How does Medicare change payments to hospitals

Has a special of secondary dx that will increase payment including

• Major complication or cormoib conditions (MCCs)

  • Complicating or cormorbid conditions (CCs)

New Patient

Has not been seen by same specialty and subspecialty member of your group in past 3 years

Established Patient

Seen by same specialty and subspecialty member of your group in past 3 years

How does evaluation and management change for new vs established patient

New → Needs history, exam, and decision-making

Established → 2 of the 3

Both can be based on time

What should documentation for billing include

• Medical indication for tests

• Past & present diagnoses

• Patient’s progress, effective and failed treatments

• Risk factors

• Support for intensity & complexity of Medical Decision Making

What are the key areas of evaluation documntation

History

Physical Exam

Medical Decision Making

What is the included in E/M hisotry

Cheif Complaint

HPI

PMH

Allergies

Medications

Social Hx

FHx

ROS

What is the included in E/M physical exam

Exam of up to 14 organ systems

what is included in E/M medical decision making

Differential Dx

Complexity of Case

Incident to Billing

Billing type that is applied to non-physician

When is Incident to Billing apply to PA

Outpatient setting

What is needed for a PA to get paid in incident to billing

• Physician is physically on site when PA provides care

• Physician must treat all new Medicare patients

• Established patients with new medical problems are personally treated by the physician

• The physician has set the plan of care

Balanced Budget Act (BBA 1997)

A law that states that physician services by the PA are covered in all settings

• Inpatient / Outpatient / ED

• Nursing Facility

• Offices and Clinics

• First Assisting

How much of the fee schedule is given for BBA 1997

85%

How much of the fee schedule is covered by Incident to billing

100%

When was Mediaid and Medicare enacted

1965

Who administers Medicaid

states

Who administers Medicaree

Federal

who is covered by Medicaid

Indigent populations

• Pregnant women

• Children

• Adults in families with dependent children

• Individuals with disabilies

• Needy elderly

Who funds Medicaid

States and federal

What is the difference in income for Medicare/Medicaid

Medicaid → Used modified adjusted gross income (MAGI)

Medicare → Not means tested

Who funds Medicare

Federal

What program was originally called “Great Society”

Medicare

What agency oversees Medicare

Center for Medicare and Medicaid Services (CMS)

Who is covered by Medicare

Over 65 y/o

Disabled

End-Stage Renal Disease

Staff Model HMO

An insurance model where the insurer employs physicians

Referall outside of the HMO physicians are not covered without approval

Preventive services are covered

Capitation

A prepaid agreement for the care of patients

The insurance company pays the provider a fixed amount of money for the amount of patients

Who holds risk for the capitation model of insurance

The provider (Only gets a fixed amount for all needs)

Indemnity Insurance

An insurance model where providers