HIPAA, Ethics, and Legal

HIPAA

Health Insurance Portability and Accountability Act

What does HIPAA protect?

It is a law put in place to protect the privacy of clients. It regulates how a client's personal health information is used and disclosed. ex: diagnosis and test results

Who can you share a client's medical information with?

Team members DIRECTLY involved in the patient's care.

-share on a need to know basis only

-no oversharing detailed information with non-essential personnel. ex: secretaries and transporters

A charge nurse from another unit goes to check on a client and states that the client is her neighbor and she just wants to check on her. What is the correct response?

I am sorry, I cannot tell you that information.

The nurse looks up the chart of a cousin who is not directly under the care of the nurse. What is the correct action the manager should take?

Contact the Human Resource department

Where should you never discuss patient info?

in the hallway, elevator, public place, or anywhere outside of the hospital.

While at work, what kind of area should you discuss patient infomation?

In a secure, private area at work such as a nurse's station or private room

When should you not access patient's charts?

When assessing for information that is not directly related to work.

What should you never share when it comes to patient charting?

Do not ever share your password even with the supervisor such as the charge nurse or the director.

What should you do to your computer when stepping away?

Log off your account. Also, log off your coworker's account if they leave the computer in the hallway unattended.

A nurse has shared his username and password with the student nurse. What are the possible consequences?

The nurse can be prosecuted.

When is it okay to take client information home?

Never

How should you dispose of report sheets?

In a shredder

Where should old physical copies of records be kept?

Locked away in a file cabinet

Do client's have the right to obtain copies of their medical records?

Yes, they have the right to do so.

What should you do when a patient's family member or friend is requestion medical information about the client?

Obtain permission from the client to disclose the information. NEVER share without permission.

A 19 year old client wants to start birth control but does not want her parents to find out, seeing she is on their insurance plan. What should the nurse tell the client?

The client's medical records may not be disclosed but the parents may find out about it through the insurance billing receipts.

What should you do when there is a breach of confidentiality of a patient's information such as a nurse discussing a client's condition in a hallway, cafeteria, or an elevator?

Report it and explain to the coworkers that this is not appropriate and they should move to a private area.

When can you take a client's report sheet home?

You can't; it must be shredded at the end of the shift.

If your client is going for a gallbladder test, what should you tell the roommate?

Your roommate is going for a test or your roommate is going to be back soon. Do not specify that it is a gallbladder test.

Can you share information with a client's legal guardian?

Not without the client's permission.

Can you tell a client to wear a mask when a patient is on isolation precautions?

Yes, you just cannot share why they are on precautions.

Is it a violation to talk about cures to a disease?

No, it does not disclose a patient's info.

Is this a violation?

The client's roommate overhears the nurse discussing client's info through the room's curtain.

No, the nurse did her best to give the information privately.

What information must be shared even if a client does not consent to it?

The patient is making comments that imply or threaten self harm, or when the patient is talking about harming others.

Autonomy

"Always in control"

A client has the right to make their own healthcare decisions. Ex: You must respect the patient's right to refuse treatment.

Advocacy

"advocate"

to protect the client's rights, health, and safety

Ex: reporting critical changes in the client's condition

beneficence

"benefit"

doing and promoting good

Ex: Calling the client's family and telling them that the client is critically ill and we are caring for their needs.

Do not give too many details over the phone such as, "the client is doing bad and we are doing CPR" because it will cause panic.

fidelity

"faithful"

to remain loyal and follow through

ex: following through with your responsibility as a nurse

The client has stated she has a level 8 out of 10 pain. The nurse promised to return to the client with pain meds. The nurse follows through with the action. What is this an example of?

Fidelity

justice

to treat fairly and equally regardless of race, gender, religion, culture, etc.

ex: Ensuring that time and resources are distributed equally between clients

Nonmaleficence

"No mal-intent"

To avoid causing harm

Ex: Double checking a drug dosage with another nurse

Veracity

"Very honest"

To tell the truth

Ex: Med error with no adverse effects but still reporting it

Tort

a wrongful act that can lead to legal liability.

Where does the burden of proof lay?

With the accuser, not the accused.

unintentional torts

"unintended" accidents that cause harm

negligence

the failure to provide adequate care that another reasonable coworker would do in a similar situation

Examples:

-practice that is below the standard of care

-Nurse fails to wash her hands before inserting a foley catheter.

-Nurse notices absence of peripheral pulse in the morning and does not report it until the afternoon.

informed consent

giving potential participants enough information about a study to enable them to choose whether they wish to participate

What can happen if informed consent is withheld from an individual?

healthcare provider could be found guilty of negligence

malpractice

illegal, improper, or negligent actions by a licensed professional.

Ex: nurse failed to check the dosage of a medicine and it harmed the client

Abandonment

desertion of a client by anyone who has assumed the responsibility of care.

Ex: Leaving without giving report to the nurse before leaving

Intentional torts

willful acts that violate a patient's rights (Assault and battery)

Assault (threat of harm) before battery

Assault

threat of harm

Ex: I am going to restrain you to the bed if you keep getting up

Threatening to place an NG tube in a client who refuses to eat

Battery

physical contact that causes harm or unconsented contact that causes harm

Ex: performing a procedure without consent

Giving medication to a client which a patient refuses

Assault and battery example

chemically restraining a patient who is competent and able to make decisions

False imprisonment

using physical restraints, seclusions, or chemical restraints to keep someone against their will (excluding psychiatric patients or those threatening harm)

Ex: Using restraints on a competent client the prevent them from leaving the facility

Invasion of privacy

violating confidentiality rights

Ex: HIPAA violations

Defamation of character

making rude, insulting remarks that harm a client's reputation

Libel

written defamation

think "library"

slander

spoken defamation

think "S" for "spoken"

Example: breakroom gossip

ANA (American Nurses Association)

establishes ethical standards for the nursing profession

Ethic committee

a healthcare team that provides guidance in the face of an ethical dilemma. Provides recommendations, does not impose decisions.

Standards of practice

The reasonable nurse test is used to determine the standard of care

Ex: What would a prudent nurse do in the same circumstances?

What would a similar nurse in the same area with the same training and background do?

informed consent

confirms a client's voluntary decision.

required before invasive procedure or surgery

When is performing a procedure without consent legal?

It isn't. It is called battery.

Charges in a legal case

Can be civil (brought on an individual) or criminal (crimes against the state) which is more serious.

Who can give informed consent?

It must be given by a competent adult such as:

-a parent or guardian of a minor

-legal guardian/court specified representative

-Healthcare surrogate (Power of Attorney/Proxy)

-spouse or closest available relative (state laws)

-Emancipated minors can give their own consent

Are patients with altered level of consciousness able to provide consent?

No because they are not competent enough to provide consent.

How do you know when a client is not competent enough to make decisions regarding their care?

When they are:

-unconscious

-having a bipolar or schizophrenic episode

-impaired with alcohol or drugs

-dementia

-delirium

Are clients who are admitted involuntarily able to make decisions about their treatment?

As long as they remain competent they have the right to consent for procedures

What should the nurse do when a patient needs emergency surgery but cannot sign a consent form due to being unconscious?

Nurse should receive telephone consent from a family member and have two authorized individuals witness to it.

Minors require parental informed consent except when:

pregnant, married, emancipated, substance abuse, STI, members of the military, and minors who are parents.

When can non-English speaking client's provide consent?

Only when a medical interpreter can translate

cannot be a family member or friend that translates.

Is it the nurse's responsibility to obtain informed consent?

No, it is the provider's, typically the surgeon

What is the nurse's job while the provider seeks patient informed consent?

to witness

What should the provider (typically the surgeon), explain to the client while seeking informed consent?

benefits, risks, and alternatives

It is also the provider's job to answer all of the client's questions. Only the provider can do this, not the nurse.

The patient wants to know about diet after the surgery and risks of the surgery. What information should the nurse provide?

The nurse can provide diet information, but must leave the information regarding risks for the provider to answer.

Who explains the right to refuse surgery?

The doctor

What should you do if the client is in surgery and needs an additional surgery?

Call the client's medical power of attorney, legal guardian, or next of kin to obtain consent for additional procedures

What does phone consent require?

Two witnesses

Nurses are responsible for witnessing informed consent, but not responsible for what?

obtaining informed consent

When referring to informed consent, what should the nurse document?

Date and time signature was obtained

When referring to informed consent, what should the nurse do regarding when the patient signs for informed consent?

Make sure the client is competent and that it is voluntary

What should you make sure of before a client signs any consent forms?

That the patient is not on sedatives

Who would sign for consent when a patient with a hx of dementia is alert and oriented x4?

the client

How should a nurse advocate for the client when they are signing for informed consent?

assess client and confirm they received and understand the info.

What kind of information can the nurse provide to the client while they are signing for informed consent?

ordinary questions like diet, exercise, and breathing after the procedure.

Do not answer specifics about the surgery or procedure. Contact HCP if patient does not understand or needs more info. Only assess and confirm understanding.

When should a patient not educate the client about the procedure?

if there is a misunderstanding, do not correct or explain. Get the HCP.

Can the nurse explain a client's rights to refuse surgery?

No, only HCP can

What should the nurse avoid doing when a patient changes their mind about surgery?

The first thing the nurse should do is notify the HCP, THEN the nurse should avoid trying to change the patient's mind by convincing them to have the surgery.

Advanced directives

legal documents that outline the patient's desired medical care if the patient becomes unable to verbalize their wishes

Glasgow Coma Scale - eye opening

4 - spontaneous

3 - open to speech

2 - open to pain

1 - no response

Glasgow Coma Scale - Verbal

5 - alert and oriented

4 - disoriented conversation

3 - inappropriate words

2 - nonsensical sounds

1 - no response

Glasgow Coma Scale - Motor

6 - spontaneous

5 - localizes pain

4 - withdraws to pain

3 - decorticate posturing

2 - decerebrate posturing

1 - no movement

Glasgow Coma Scale scoring

Mild 13-15

Moderate 9-12

Severe 3-8

What should you do once advanced directives are put into place?

Put a copy in the patient's medical records

Copies should be given to family, friends, and everyone listed as medical proxies.

What is an example of a concerning statement from a client?

My living will is secured at home in my safety deposit box

Do advanced directives need to be notarized?

No, there only needs to be 2 witnesses that are not the nurses or the HCPs directly involved in the client's care. They also cannot be individuals named as healthcare proxies.

What should a nurse do if there is no advanced directives found?

Do whatever a reasonable person would choose in the situation. Typically full treatment or full lifesaving measures.

A client is newly diagnosed with mild Alzheimer's disease. What is the priority teaching that the nurse should provide to the client and the client's family?

Encourage the client to make an advanced directive BEFORE client's cognitive function declines further.

Key points about advanced directives

It is separate from a final will.

It is a document that describes the type of treatment the client wanted.

Types of advanced directives

living will and durable power of attorney

Durable POA

assigns another person, healthcare proxy, or surrogate(s) to make medical decisions for the client if the client becomes incapacitated.

If the wife and sister (who has the medical POA) both want to make a decision about the client, who has the final say?

The sister because she has the medical POA.

What should you clarify when it comes to POA?

Since there are different types of POA, it is important to clarify who has the medical POA.

living will

a signed document that outlines wishes and desired medical care if the client becomes incapacitated or unable to communicate.

What does a living will outline when it comes to medical treatment?

level of interventions

life-sustaining measures (ex: ventilator or tube feedings)

code status

Code status: full code

full resuscitative measures

Code status: chemical code

medications only (no CPR, electric shock or respirations)

Code status: DNR

do not resuscitate