U3 Self Study Resources 1-3

What does a Living will entail?

explains a patient’s wishes about life-sustaining medical treatments if they become terminally ill, permanently unconscious, or unable to communicate. It states which care the patient does, or does not, wish to receive.

What is Medical/Durable Power of Attorney for Healthcare/Health Care Power of Attorney?

designates a healthcare agent or proxy (a chosen person) to make medical decisions for the patient if they’re unable to do so. This only applies to healthcare-related decisions.

What is a Do Not Resuscitate (DNR)/Do Not Intubate (DNI) order?

medical directives that tell healthcare providers what life-saving measures a patient does not want if their heart or breathing stops.

What is Medical Orders for Life Sustaining Treatment (MOLST) or Physician Orders for Life Sustaining Treatment (POLST)?

turns the patient’s wishes expressed in his living will into an actual provider order. It provides clear, actionable orders for emergency and healthcare personnel to follow, even outside of the hospital (at home, in nursing facilities, or during EMS transport).

Define Legal Guardianship

are court-appointed relationships where one person is given the legal authority to make decisions on behalf of another who is unable to make decisions independently due to age, disability, or incapacity. Legal guardians can give informed consent for procedures.

What are 4 principles of Medical records?

• provide an account of the health care a patient has received over time.

• With a patient’s consent, medical records can be shared with new providers

• “minimum necessary” standard

• Disclosing a patient’s record requires a patient’s consent, except for permitted disclosures.

What are 2 components of Medical records guidelines?

• Protected Health Information (PHI) must be safeguarded in both paper and electronic records.

• Records must be maintained accurately and legibly and be retrievable(active&archived)

What are 5 components of Medical Record Retention guidelines?

• HIPAA requires covered entities to retain certain documents for 6 years from creation or last effect.

• Retention guidelines for medical records are established by state laws, federal programs, and

  licensing boards.

• Texas- requires facilities to retain medical records for a minimum of 7 years from the

  anniversary date of the last treatment by the physician. (for 7 yrs OR until 21 for minors- whichever is longer)

• Medical records that are part of civil, criminal, or administrative proceedings should not be

  destroyed until the proceeding has completely resolved

• When guideline conflict always follow the longer guideline.

What are 2 components of Medical Record Disposal & Destruction?

• Dispose of PHI by secure methods (ex: cross-cut shredding, incineration)

• Follow facility policy for maintaining destruction logs (what was destroyed, when, how, and

  who witnessed the destruction).

What are the 3 Special situations- and what should be done during them?

• Legal holds: Do not destroy medical records if any litigation or complaint is pending.

• Mental health records are kept separate from the rest of the medical

  record. Mental health records require specific written consent to be released.

• Substance abuse records are only shared with specific patient consent unless there is a medical emergency, court order, or mandated reporting situation.

When and by who was the Patients Bill of Rights created?

• 1973

• American Hospital Association (AHA)

What are the 8 components of the Patients Bill of Rights?

1. Right to information

2. Right to choose

3. Right to privacy and confidentiality

4. Right to respectful care

5. Right to refuse treatment

6. Right to emergency care

7. Right to review records

8. Right to complain or appeal

What does AMA stand for? What are it’s implications?

• Against Medical Advice

• asked to sign an AMA form documenting that they understand and accept the risks.

• document the attempt and the patient’s refusal to sign.

• Patients should be provided with appropriate care and instructions prior to leaving.

21st Century CURES Act

• promotes medical innovation

• improves patient access to health information

• supports mental health and opioid treatment programs

• speeds up drug dev. & med. devices

• helps patients access health records.

Affordable Care Act (ACA)

“Obamacare,” this law expanded access to affordable health insurance, improved healthcare quality, and prohibited discrimination based on preexisting conditions

Americans with Disabilities Act (ADA)

Prohibits discrimination against individuals with disabilities and ensures equal access to employment, public services, transportation, and accommodations.

Americans with Disabilities Act Amendments Act (ADAAA)

2008 update to the original ADA broadly defines the term “disability” to provide broader coverage

Anti Kickback Statute (AKBS)

Federal law that prohibits offering, paying, soliciting, or receiving anything of value to influence the referral of services or items covered by federal healthcare programs.

Clinical Laboratory Improvement Act (CLIA)

Federal regulations that set quality standards for laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results

Controlled Substances Act (CSA)

• Federal law that regulates manufacturing, distribution, and use of drugs with potential for abuse by classifying them into schedules based on their medical use and risk of dependence.

• Effort to combine all previous federal drug laws and allow for federal law enforcement of controlled substances,

Emergency Medical Treatment and Active Labor Act (EMTALA)

Federal law that requires hospitals to provide emergency medical screening and stabilizing treatment to anyone seeking care, regardless of their ability to pay or insurance status.

Genetic Information Nondiscrimination Act (GINA)

Federal law that prohibits discrimination in health insurance and employment based on an individual’s genetic information.

Good Samaritan Acts

Protects individuals who decide to provide help and serve those who are injured in the community. Healthcare workers are protected in these situations when they act within their scope in a reasonably prudent manner

Health Emergency Response Coordination Act (HERCA)

Creates a system for organizing and coordinating state and local responses to public health emergencies.

Health Insurance Portability and Accountability Act (HIPAA)

Act of Congress passed in 1996 that affords certain protections to persons covered by health care plans, including continuity of coverage when changing jobs, standards or electronic health care transactions, and privacy safeguards for individually identifiable patient information

HIPAA Privacy Rule

Provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information

HIPAA Security Rule

Establishes national standards to protect individuals’ electronic personal health information that is created, received, used, or maintained by a covered entity.

No Surprise Act

Protects patients from unexpected medical bills when they receive emergency care or certain out-of-network services at in-network facilities.

Patient Safety and Quality Improvement Act (PSQIA)

encourages healthcare providers to report and share information about medical errors and safety events to improve patient care.

Title VII of Civil Rights

• Prohibits employment discrimination based on race, color, religion, sex, ornational origin.

• It also protects employees from retaliation for filing a complaint or participating in an investigation related to discrimination.

• Employers are also prohibited from discriminating against pregnancy and childbirth.

• Sexual harassment is a violation of Title VII.

Uniform Anatomical Gift Act (UAGA)

Governs that legislation governing organ donations is substantially the same from state to state for the organ transplantation and the gift one’s deceased body for use in the study of medicine

Whistleblower Protection Act

Protects employees who report illegal, unethical, or unsafe practices from retaliation by their employers. It encourages transparency and accountability.

Beyond a Reasonable Doubt

Being sure of a criminal defendant’s guilt to a moral certainty

Capacity

Having the mental competency to make healthcare decisions or execute a will at the time the will was signed and witnessed.

Compensatory Damages

Damages recovered in payment for actual injury or economic loss, which does not include punitive damages (as added damages due to malicious or grossly negligent action)

Conflict of Interest

Physician self-referral is the practice of a physician referring a patient to the medical facility in which they have a financial interest, be it ownership, investment, or structured compensation agreements.

Consent

Permission given for something

Defendant

Party sued in a civil lawsuit or the party charged with a crime in criminal prosecution

Distributive Justice

Principle by which we as a society, or healthcare community, decide to allocate resources that are in scarce supply

Elder Abuse

Any abuse (physical, sexual, psychological, emotional, or financial) and neglect of persons aged 60 and older by a caregiver or another person in a relationship involving an expectation of trust.

Emancipated Minor

Person who is not legally an adult of 18 years of age but who may not require parental permission for medical or surgical care

Ethics

Rules of conduct with respect to a particular class of actions, based on ideas about what is morally good and bad

Exploitation

Also called financial abuse, this is the unauthorized or improper use of the resources of an elder for monetary or personal benefit, profit, or gain.

Express Consent

Patient directly communicates their consent to the physician or healthcare worker either in writing, by signing papers, or orally through verbal communication.

Felony

Crime sufficiently serious to be punishable by death or a term in state or federal prison

Gross Negligence

Carelessness to the point of reckless disregard for the safety or lives of others, and so great it appears to be a conscious violation of other people’s right to safety.

Guardian

Person who has been appointed by a judge to take care of a minor child or incompetent adult personally and/or to manage the person’s affairs

Implied Consent

Assumption that an unconscious person would consent to emergency care if they were conscious and able to consent. A conscious person demonstrating consent through physical actions, like holding out an arm for a blood pressure. Implied consent can never overrule informed consent, express consent, or the explicit rejection of care.

Informed Consent

Agreement to do something or allow something to happen only after all relevant facts are known, including risks, benefits, and alternatives

Liability

Anything to which a person is liable, responsible, or legally bound, including debts and accounts payable owed by the business

Libel

Written form of defamation

Mature Minor

Enables the provider to ask questions of the young person in order to determine whether or not the minor has the maturity to provide their own consent for treatment, typically pertaining to mental health, pregnancy, and STD care

Mediation

Type of dispute resolution where the parties to a lawsuit meet with a neutral third party (the mediator) in an effort to settle the case.

Medical Malpractice

Act or continuing conduct of a healthcare worker or facility that does not meet the standard of professional competence and results in provable damages to the patient

Misdemeanors

Lesser crimes punishable by a fine and/or county jail time for up to one year

Morals

Pertaining to the distinction of right and wrong

Neglect

Failure or refusal of a caregiver or responsible person to provide for someone’s basic physical, emotional, or social needs, failure to protect a child or elder from harm

Negligence

Guilty of neglect, lacking in due care or concern, act of carelessness

Non-maleficence

Obligation to do no harm

Plaintiff

Party that initiates a lawsuit by filing with the clerk of the court against the defendants demanding damages, performance, and/or court determination of rights

Privileged Communications

Communication between parties to a confidential relation (such as provider-patient relationship) such that the recipient cannot be legally compelled to disclose it as a witness

Professional Ethics

Framework of evaluating conduct applicable to members of a given profession, 4 pillars in healthcare

Punitive Damages

Damages awarded in a lawsuit as a punishment and example to others for malicious, evil, or fraudulent acts

Risk Management

Identification of all exposure to financial loss of a business and includes the selection of techniques to manage those exposures; clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself

Slander

Spoken defamation

Standard of Care

The watchfulness, attention, caution, and prudence that a reasonable person would exercise in the same circumstances

Statute of Limitations

A statute prescribing a period of limitations for bringing certain kinds of legal action

Torts

A civil wrong, other than a breach of contact, where one party’s breach of legal duty causes harm to another, entitling the injured party to seek remedies such as monetary damages or injunctions.

Values

Beliefs that are important to a person or organization, which influences attitudes or behavior

Vicariously liable

Attachment of responsibility to a person for harm or damages caused by another person in either a negligence lawsuit or criminal prosecution

Abandonment

Medical provider ends the patient-provider relationship without providing enough notice of ensuring the patient has access to alternative care.

Assault

Wrong act of causing someone to reasonably fear imminent harm

Autonomy

Independence or freedom of an individual’s will, the right to choose.

Battery

An intentional tort, meaning a person intentionally causes harmful or offensive contact with another person

Beneficence

Doing good for another, the act of caring

Arbitration

 Private, judicial determination of a dispute and an alternative to court action (litigation), generally just as final and binding