EMR - Legal Notes

Confidentiality:

     The ethical principle or lefal riht that a health care professional will hold secret all information related to a patient, unless the patient gives consent permitting disclosure. By law, you can only share info if another HCP needs it, or if it’s subpeanad for court.

Consent

    Implied Consent:

        Consent assumed when a pt is unable to express

  • Under the influance of alcohol/drugs

  • Alterd mental status

  • Mental illness or intellectual disability

  • (May need help from police to povide care under the Mental Health Act)

    Informed Consent:

        Pt voices or writes consent to care when indormed.

    Pedeatrics:

        A parent/guardian must give consent before you treat a minor unless…

  • a life threatening condition exists

  • The individual is an emancepated minor (not under control)

  • They are alone

  • ~16 can consent for themself

        There is a lot fo grey areas here

Negligence:

    Carelessness, inatention or disregard that was unitentionial but avoidable. You must adhere to a standard of care

Abandonment:

    the removal of care before transferring to another HCP. Once care is started, you must continue until equal or a higher trained person takes over.

Duty to Act:

    Responders, while working are compelled to provide care by law. Your responsibiliyt to provide care while employed to do so

Indirect Medical Control

    Follow standing orders and protocols in which you are trained

Direct Medical Control

    Consult medical control (Clinicall, ALS, etc) with questions about scope of practice or care

Refusal of Care:

    Competent adults (16+) can refuse help but must be told of the consequenses of the refusal

  • Try to persuade the pt

  • Ensure the pt can make informed decisions (not under the influiance of drugs/alcohol or suffering from mental health issues)

  • have pt sign refusal form (AMA)

  • ancourage pt ot seek help if symptoms persist

  • advise pt call EMS again if they change their mind

  • DOCUMENT EVERYTHING!

Advanced Directives:

  • Do Not Resusitate order (DNR)

  • Medical Orders for Scope of Treatments (MOST)

  • You must SEE the SIGNED paperwork before withdrawling care.

Empathy:

    active, understading of someone’s feelings as if there were your own, getting to the root of the problem and offering comfort.

Sympathy:

    Passive, feeling sorry for someone from own POV, offering unsolicited advice and pasive judgement.

Common Assault

    Obtain consent before touching pts clothes or body

Protocol:

    Step by step approach to particular trauma or medical situations

Guideline

    More fluid, uses expirience and clincall judgement, less linear

Documentatioon

  • Record all vitals, PMHx, and findings

  • One line through mistakes if on paper

  • Many orgs. use electronic records. (ex. BCEHS)