Chapter 24, 25, 26 Introduction to Radiologic and Imaging Sciences and Patient Care

legislative law

administrative rules

regulations

ordinances

case law

derived from the common law of England

laws determined on a case by case basis

(statutory law)

characteristics of law

laws must be equal to all without discrimination

law is based on what a reasonable and prudent person would do in similar circumstances

all individuals have basic rights and responsibilities

standard of care

the degree of sill, knowledge, and care ordinarily possessed and employed by members in good standing within the medical profession

standard of care

judged against reasonable and prudent actions under similar circumstances

tort

a civil lawsuit to remedy a wrongful act

laws

the body of rules, regulations and guide that govern conduct in society to protect health, safety and welfare of its citizens

1914

schloedndorg v society when patient consent was established as a necessity otherwise its an assault

Doctrine of Patient-Provider Relationship

protects individual autonomy

protects the patient's status as a human being

avoids fraud and duress

encourages health care practitioners to consider their decisions carefully

fosters rational decision making by the patient

involves the public in medicine

types of laws

constitutional

legislative

case law

contract law

tort

comes from a violation of a duty imposed by general law, a breach of duty must occur to warrant tort action

assault

may arise when a patient believes he or she has been threatened in such a way that reason to fear or to expect immediate bodily harm exists, does not require physical contact, may be only verbal. But if patient perceives possible harm by comments, assault can be present

battery

may occur even if no injury arises from unwarranted patient contact, any unlawful touching may constitute battery if the patient thinks that the technologist has touched him or her in an offensive way

permission base

when positioning patients, we touch but it is all

false imprisonment

arises with a person is restrained or believes that he or she is being restrained against their will, the individual must be aware of the confinement and have no reasonable means of escape

defamation

slander and libel

slander

spoken defamation

libel

written defamation

fraud

a willful and intentional misrepresentation of facts that may cause harm to an individual or result in loss of an individual right or property

fraud

cases require three sources of proof:

an untrue statement

the injured party relied on statement

damages were incurred as a result

Patient Care Bill of Rights

clearly defines that health records are to be held in private and confidential

health provider

health records are the property of _____-

Negligence

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

Negligence Proof

duty

breach

causation

damage

Respondeat Superior

the master speaks for the servant

res ipsa loquitor

the thing speaks for itself

the principle of autonomy

-Right to information and self-determination

-Free and informed consent

-Free will and accord—intentional participation in treatment

-Respect and dignity maintained

APC

Classification system of patients based on the International Classification of Diseases, clinical modification codes for diagnoses, current procedural terminology evaluation and management codes, and procedure codes, age, sex, visit disposition used for reimbursement for health care provided in the hospital outpatient setting

CPT-4 stands for

Current Procedural Terminology, 4th edition

APC stands for

Ambulatory Patient Classifications

CPT-4

Comprehensive list of medical terms and codes for the uniform designation of diagnostic and therapeutic procedures; used in the United States for coding for physician reimbursement and hospital outpatient and ambulatory surgical procedures

DRGs stands for

Diagnosis Related Groups

DRG

System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

EHR stands for

electronic health record

EMR stands for

electronic medical record

EHR/EMR

electronic record system generally considered as the portal through which clinicians access a patient's health record, order treatments or therapy, and document care delivered to patients; allows providers to gather multiple types of data about a patient (clinical, financial, administrative, and research)

HFAP stands for

Healthcare Facilities Accreditation Program (Accrediting organization for AOA. Provides accreditation programs for primarily osteopathic hospitals)

HFAP

an accreditation program "authorized by the Centers of Medicare and Medicaid Services (CMS) to survey" all hospitals and many other types of health care settings (Healthcare Facilities Accreditation Program, 2017)

Health Information Management Practitioners

term used to encompass both registered health information administrators and registered health information technicians as individuals with either of these credentials who hold a variety of positions within the health information management profession

HIPAA stands for

Health Insurance Portability and Accountability Act of 1996

HIPAA

Federal legislation passed to improve the efficiency and effectiveness of the health care system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information

health records

Permanent or long-lasting documentation of all patient care information that applies to individual patients

ICD-9-CM stands for

International Classification of Diseases, 9th Revision, Clinical Modification

ICD-9-CM

A classification system used in the United States to report morbidity and mortality information until September 30, 2015

ICD-10-CM stands for

International Classification of Diseases, 10th Revision, Clinical Modification

ICD-10-CM

the classification system that replaced ICD-9-CM, Volumes 1 and 2 on October 1, 2015. This classification system is used for diagnosis coding in all health care settings in the United States

ICD-10-PCS stands for

International Classification of Diseases, 10th Revision, Procedure Classification System.

ICD-10-PCS

a classification system used in the United States for reporting of inpatient hospital procedures. This classification system replaces the ICD-9-CM Volume 3 procedure codes on October 1, 2015

The Joint Commission

Organization that accredits and certifies health care organizations and other programs in the United States

Performance Improvement

process by which the quality of the care and services provided to patients within a health care facility is monitored and evaluated

PPS stands for

Prospective Payment System

PPS

system for Medicare patients by which a predetermined level of reimbursement is established before services are provided

RHIAs stands for

Registered Health Information Administrators

RHIAs

professionals who possess the expertise to develop, implement, and/or manage individual, aggregate, and public heath care data in support of patient safety and privacy, as well as confidentiality and security of health information

RHITs stands for

Registered health information technicians

RHITs

professionals who are technical experts in health data collection, analysis, monitoring, maintenance, and reporting activities in accordance with established data-quality principles, legal and regulatory standards, and professional best practice guidelines

performance improvement

quality assurance, quality assessment, and performance improvement are all used to encompass activities related to ______ _____, including utilization and risk management, infection control, surgical case review, medication usage evaluation, health record review, blood usage review, pharmacy and therapeutic review, and case management.

5

information must be maintained a minimum of ___ years from date of last patient visit

service

health information department is ____ oriented

contigent

many reimbursement formulas are ______ upon medical records and their accuracy

health information department

supports medical education programs

apc

based on ICD-10-CM codes for diagnosis and CPT codes used for reimbursement to health care in an outpatient setting

CPT-4

listing of medical terms and codes for diagnostic and therapeutic procedures used for coding for physician reimbursement (both inpatient and outpatient)

ICD-10-CM

classification system that is used for diagnosis coding in all health care settings in the United states)

DRG

categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

TJC

Organization that accredits hospitals and other health care institutions in the United States

HFAP

performs functions similar to TJC

PPS

System for Medicare patients whereby payment groups are established in advance; hospitals get paid up front

According to the Joint Commission and Healthcare Facilities Accreditation Program

a medical record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote the continuity of care among health care providers

According to Medicare

a medical record must contain information to justify the admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to the medication and services

health records coding

considered a very high priority in the operation of a health care organization

health records coding

requires physician recording of a patient diagnosis/procedure upon discharge

ICD-10-CM and CPT-4

It is important for radiology personnel to understand the diagnostic codes of:

diagnostic or therapeutic

Documenting in the patient's record, or charting, should be done by radiologists and radiographers when a patient receives either ____ or ____ radiologic services

DRG and PPS

Medical records contain sufficient information to support the diagnosis for reimbursement purposes under the __ and ___ implemented by the government in 1983

right/left marker

The third thing needed to make a radiograph legal? It is within our control

Autonomy

person's self-reliance, independence, liberty, rights, privacy, individual choice, freedom of the will, and self-contained ability to decide.

Beneficence

Doing of good; active promotion of goodness, kindness, and charity.

Caring

Care for; an emotional commitment to and a willingness to act on behalf of a person whom a caring relationship exists.

Codes of Ethics

articulated statement of role morality as seen by the members of a profession.

Adopted by the American Registry of Radiologic Technologist.

Confidentiality

Belief that health related information about individual patients should not be revealed to others; maintenance of privacy.

Consequentialism

Belief that the worth of actions is determined by their ends of consequences; actions are right or wrong according to the glance of their good and bad consequences.

Duties

Obligations placed on individuals, groups, and institutions by reason of the so-called moral bond of our interdependence with others.

Ethical Dilemmas

Situations requiring moral judgment between two or more equally problem-fraught alternatives; two or more competing moral norms are present, creating a challenge about what to do.

Situations that test our ethics.

EX: we might agree that refusing to provide services to dirty, unkempt patients or to those with acquired immunodeficiency syndrome (AIDS) is unethical, but we might hold a variety of opinions on what degree of loyalty we owe to our fellow workers not he health care team.

Ethical outrage

gross violation of commonly held standards of decent or human rights.

Ethical theories

Bodies of systematically related moral principles used to resolve ethical dilemmas.

Sets of principles that tell us what actions are right or wrong.

Ethics

study of rightness and wrongness of human conduct/character

Self-discipline.

Ethics of care

Ethical reflections that emphasize an intimate personal relationship value system that includes such virtues as sympathy, compassion, fidelity, discernment, and love.

emphasizes the need for an accurate understanding of moral competence, a clear vision of the meaning of a virtuous person and finely honed skills in human relations.

Fidelity

Strict observance of promises or duties; loyalty and faithfulness to others.

Justice

equitable, fair, or just conduct in dealing with others.

Laws

Regulations established by government and applicable to people within a certain political subdivision.

Legal Rights

Rights of individuals or groups that are established and guaranteed by law.

liberal individualism

basis for rights-based ethical theory; each individual is protected and allowed to pursue personal projects.

Moral Principles

general, universal guides to action that are derived from so-called basic moral truths that should be respected unless a morally compelling reason exists not to do so; also referred to as ethical principles.

Morals Rights

rights of individuals or groups that exist separately from governmental or institutional guarantees; usually asserted based on moral principles or rules.

Moral Rules

Statements of right conduct governing individual actions.

Morals

Generally accepted customs/ habits of right living

nonconsequentialism

Belief that actions themselves, rather than consequences, determine the worth of actions; actions are right or wrong according to the morality of the acts themselves.

EX: consequentialist would lie to a patient if he thinks it will ultimately benefit. A nonconsequentialist would caution against lying to a patient under any circumstances because the act of lying is generally accepted as morally wrong in our society.

Nonmaleficence

ethical principle that places high value on doing no harm to others.

Norms

standards set by individuals or groups of individuals.