Module 9: Chapter 24-26 Medical Law Ethics

What is the principle of beneficence in healthcare?

To perform actions that benefit others and always act to benefit the patient.

What does nonmaleficence mean?

To do no harm and never perform or allow acts that may harm the patient.

What is autonomy in the context of patient care?

To respect the independence of other persons, allowing patients to decide what is done to their own bodies.

What does veracity refer to in professional ethics?

Being truthful; it is expected to tell the truth.

Define fidelity in professional ethics.

Performing acts that observe covenants or promises is considered right.

What does justice mean in the context of healthcare ethics?

Performing acts that ensure the fair distribution of goods and harm.

What are the two main documents that define professional behavior?

Professional Standards of Conduct and Scope of Practice.

What is the ARRT Code of Ethics?

A document that establishes professional norms of conduct for radiologic professionals.

What are the two parts of the ARRT Code of Ethics?

Part A outlines aspirational behaviors, while Part B details mandatory rules of acceptable conduct.

What are the ARRT Rules of Ethics?

Mandatory standards of minimally acceptable professional conduct for all certificate holders and candidates.

What is an ethical dilemma?

A situation where the correct choice is not clear and personal values may conflict.

What are the steps involved in ethical analysis?

Identification of the problem, developing alternative solutions, selecting the best solution, and defending the selection.

How should professionals handle mistakes in radiology?

Acknowledge the mistake honestly and take corrective action.

What does CPT-4 stand for?

Current Procedural Terminology, Fourth Edition, a listing of medical terms and codes for diagnostic and therapeutic procedures.

What is ICD-10-CM used for?

It is a classification system used for diagnosis coding in all healthcare settings in the United States.

What does DRG stand for?

Diagnosis-Related Group, which categorizes patients into payment groups based on diagnosis and treatment.

What is the purpose of the TC organization?

To accredit hospitals and other healthcare institutions in the United States.

What does PPS stand for in healthcare?

Prospective Payment System, which establishes payment groups for Medicare patients in advance.

What is an EMR/EHR?

Electronic Medical Record/Electronic Health Record, a system through which clinicians access and document patient care.

What is the role of Health Information Management?

To maintain all patient care information that applies to an individual patient.

What is the purpose of ICD-10-CM?

It is a classification system used for diagnosis coding in all healthcare settings in the United States.

What does DRG stand for and what is its function?

Diagnosis-Related Group; it categorizes patients into payment groups that are medically related in terms of diagnosis and treatment.

What is the role of TC in healthcare?

TC is an organization that accredits hospitals and other healthcare institutions in the United States.

What is the PPS system?

Prospective Payment System; it establishes payment groups in advance for Medicare patients, allowing hospitals to be paid upfront.

What are EMR and EHR?

Electronic Medical Record and Electronic Health Record; systems that allow clinicians to access patient health records, order treatments, and document care.

What is the primary function of Health Information Management?

To maintain all patient care information that applies to an individual patient, ensuring effective communication and continuity of care.

What are the key components of HIPAA?

Privacy, security, and standards for electronic transmission of health information.

What is the significance of accurate health records coding?

Accurate coding impacts reimbursements from Medicare and third-party payers.

What must accompany each radiology order?

A diagnosis or symptoms for which the test is being performed.

What is required for informed consent?

The patient must be informed of the procedures, risks involved, and possible consequences before signing the consent form.

What is an incident report?

A report containing information about patient incidences or occurrences that are out of the normal experience, classified as sentinel events.

What is the legal status of health records?

Health records are considered legal documents.

What information is typically included in a medical record?

Patient ID and demographics, medical history, clinical observations, diagnostic and therapeutic orders, and consultation reports.

What is the purpose of the health information department?

To support patient care, maintain health information, and assist with administrative processes such as billing.

What should be documented in radiology reports?

Patient images, procedure results, medical necessity documentation, and special reports for evaluation or treatment.

What are the do's and don'ts of recording information in medical records?

Do: Write legibly, use correct spelling, and keep information concise. Don't: Use pencil, block out entries, or include unnecessary details.

What is the importance of maintaining health records?

They promote effective communication, ensure continuity of care, and protect patient privacy.

What is required for a radiology procedure to be performed?

A completed radiology order or request for service must be submitted.

What is the role of the interpreting radiologist in radiology reports?

The report must be signed by the interpreting radiologist, and electronic signatures are typically used.

What does the term 'medical necessity' refer to in health records?

It refers to the requirement that a diagnosis or symptoms must justify the need for a procedure.

What is the significance of the date and time in medical record entries?

Each entry should begin with the date and time to ensure accurate record-keeping.

What is the purpose of health records in relation to reimbursement?

Health records must contain sufficient information to support the diagnosis for reimbursement purposes under the diagnosis-related group (DRG) and the prospective payment system (PPS).

What legal status do health records hold?

Health records are considered legal documents and original records are never left in court.

What is the proper method for correcting an error in a medical record?

The author should draw a single line through the error, write 'ERROR,' record the correct information, and date and authenticate the entry.

What does HIPAA stand for and what does it regulate?

HIPAA stands for the Health Insurance Portability and Accountability Act, which regulates the confidentiality and security of medical information.

What is the doctrine of 'respondeat superior'?

'Respondeat superior' means 'the master speaks for the servant,' holding employers liable for the actions of their employees.

What is 'corporate liability' in healthcare?

Corporate liability requires healthcare providers to be responsible for the quality of care provided.

What does 'res ipsa loquitur' mean in legal terms?

'Res ipsa loquitur' translates to 'the thing speaks for itself,' indicating that the evidence is clear without needing further explanation.

What is the standard of care in healthcare?

The standard of care is the degree of skill, knowledge, and care ordinarily possessed and employed by members of the medical profession.

What constitutes negligence in healthcare?

Negligence is a failure to use such care as a reasonably prudent person would use under similar circumstances.

What are the components that must be proven in a negligence claim?

The components are duty, breach of duty, causation, and damage.

What is the difference between informed consent and implied consent?

Informed consent involves providing information in lay language and obtaining a signed consent form, while implied consent is assumed for simple procedures or emergencies.

What rights do patients have regarding their health records?

Patients have the right to access their records, and health records are considered private and confidential.

What is the responsibility of a technologist regarding patient information?

Technologists should not release medical information and must refer patients to their physician for examination results.

What is 'false imprisonment' in the context of healthcare?

False imprisonment occurs when a person is restrained against their will and is aware of the confinement with no reasonable means of escape.

What is the definition of defamation in a healthcare context?

Defamation involves making false statements that harm a patient's reputation, which can be classified as slander (spoken) or libel (written).

What constitutes fraud in healthcare?

Fraud is a willful and intentional misrepresentation of facts that may cause harm or result in loss of rights or property.

What is the principle of autonomy in patient care?

The principle of autonomy ensures a patient's right to information and self-determination in their treatment decisions.

What should be done if a patient claims to have been wronged?

Patients may claim injury or wrongdoing, which can lead to legal action for damages based on tort law.

What is the importance of social media in healthcare?

Healthcare professionals must be cautious with social media to avoid disclosing confidential patient information, which can lead to legal issues.

What should be done with medical images and records?

Copies of written interpretations should be maintained with the images and the patient's medical records.

What is the role of the American Society of Radiologic Technologists?

The American Society of Radiologic Technologists outlines practice standards for medical imaging and radiation therapy.

What is the significance of the case Schloendorf v. Society of New York Hospital?

This case established that every adult has the right to determine what shall be done with their own body, emphasizing the need for patient consent.

What is the responsibility of healthcare practitioners in terms of patient autonomy?

Healthcare practitioners must respect patient autonomy and ensure informed consent is obtained before procedures.

What is the definition of battery in a healthcare context?

Battery occurs when there is unlawful touching of a patient without consent, which can happen even if no injury occurs.