3 Medical Law and Ethics Lesson 3: Documentation and Regulations

Lesson Objectives Lesson Objectives Upon completion of this lesson, students should be able to: Discuss the role of the medical assistant relating to legal issues in the medical office. 2

Documentation If an action is not recorded on the medical chart, it is considered by most courts not to have been performed If it isn't written, it wasn't done. 3

Critical Thinking Questions Why is documentation so important? Give some examples. 4

Documentation Calls Visits Treatments No-shows Appointment cancellations 5

Documentation Medications Prescription refills Vital signs Other pertinent information 6

Documentation Use of Records in Litigation Litigation: lawsuit tried in court Court of law may subpoena a medical record Only the parts of the record requested should be copied and sent to requesting attorney 7

Documentation Use of Records in Litigation Unless original record is subpoenaed, a certified photocopy may be sent If original record is subpoenaed, then make a copy and return the copy to locked file 8

Documentation Use of Records in Litigation Receipt for subpoenaed record should be placed in patient's file Patient should be notified his or her record has been subpoenaed Both subpoenaed record and notification to patient should be sent by certified mail 9

Documentation Use of Records in Litigation Be especially careful when using a fax transmission for medical records Confidential material is not generally sent over a fax transmission Fax not usable when original record is requested Fax cover sheet used compliant with HIPAA 10

Documentation Use of Records in Litigation Should you or your employing physician receive a subpoena ducestecum remember that only the records specifically stated in subpoena are required 11

Documentation Court Testimony Attorney may interrogate a witness Deposition: written statement taken of oral testimony given in front of a court officer Attorney submits deposition during court case 12

Documentation Court Testimony Arraignment occurs when defendant is called before the court to answer a charge Expert witness is a person called on to testify in court regarding the proper standard of care for a patient in a similar community 13

Documentation Court Testimony Be professional Remain calm, dignified, and serious Do not answer questions you do not understand Only present facts surrounding the case Do not memorize your testimony ahead of time Always tell the truth 14

Documentation Court Testimony Arbitration: hearing or determination of the outcome of a dispute or the settling of a difference between parties by a person or persons selected to direct the parties to an agreement 15

Public Duties of Physicians Births Stillbirths Deaths Communicable illnesses or diseases Drug abuse 16

Public Duties of Physicians Rape Abuse of children or elder adults Gunshot and knife wounds Animal bites 17

Public Duties of Physicians Births Issuing a legal certificate of birth Used as a legal proof of age Required for many benefits and documents: Social Security Passport Driver's license 18

Public Duties of Physicians Deaths Physicians sign a certificate indicating cause of a natural death Each state has specific requirements 19

Public Duties of Physicians Deaths Coroner or health official will have to sign a certificate in the following cases: No physician present at the time of death Violent or unlawful death Death as a result of criminal action Death from an undetermined cause 20

Critical Thinking Question What is the purpose of a death certificate? 21

Public Duties of Physicians Reportable Communicable Diseases Physicians must report all diseases that can be transmitted from one person to another and considered a general threat to the public Each state specific reporting requirements Report can be either by mail or phone 22

Critical Thinking Question Why is the reporting of communicable diseases necessary and required? 23

Public Duties of Physicians Reportable Communicable Diseases Diptheria, tetanus toxoids, pertussis vaccine (DTP) Pertussis vaccine (whooping cough) Measles, mumps, rubella (MMR) Poliovirus vaccine, live Poliovirus vaccine, inactivated Hepatitis B vaccine Tuberculosis test 24

Critical Thinking Question Why might the government require childhood vaccines? 25

Public Duties of Physicians Reportable Injuries Certain injuries reportable according to state requirements Gun or knife wounds Rape and battered persons injuries Spousal abuse Child abuse Elder abuse 26

Critical Thinking Question Why is the reporting of injuries necessary and required? 27

Public Duties of Physicians Child Abuse Questionable injuries reportable in some states Bruises Fractured bones Burns Malnutrition Poor growth Lack of hygiene 28

Critical Thinking Question Why is the reporting of child abuse necessary and required? 29

Public Duties of Physicians Elder Abuse Reporting agency varies by state but generally includes social service agencies Reportable in most states: Physical abuse Neglect Abandonment 30

Critical Thinking Question Why is this reporting of elder abuse necessary and required? 31

Public Duties of Physicians Drug Abuse Abuse of prescription drugs reportable according to law Such abuse can be difficult to determine because abuser may seek prescriptions for same drug from several different physicians Physician will want to see a patient before prescribing a medication 32

Drug Regulations U.S. Food and Drug Administration (FDA) Federal government agency Jurisdiction over testing and approving drugs for public use Drug Enforcement Administration (DEA) Branch of U.S. Justice Department Regulates sale and use of schedule drugs 33

Drug Regulations Controlled Substances Act of 1970 Physician who dispenses, purchases, administers, prescribes, or handles drugs required to register with DEA Controlled drugs must be kept in a double-locked cabinet and any theft immediately reported to DEA office and local police 34

Drug Regulations Controlled Substances Act of 1970 Records must be kept to document administering and dispensing of controlled drugs 35

Critical Thinking Questions A physician is dispensing morphine to a patient whom you suspect is addicted to the drug. You suspect the physician of illegally dispensing this drug for a nonexistent problem. What do you do? You come to work one day and notice that the lock for the controlled substance cabinet has been tampered with. What do you do? 36

Drug Regulations Controlled Substances Act of 1970 Controlled drugs classified into five schedules (categories) that indicate levels of potential abuse Schedule I drugs have highest potential for addiction and abuse Schedule V drugs have the least Medical assistant may not dispense controlled substances 37

Drug Regulations Medical Assistant and Drug Regulations May administer medication only under direct supervision of a physician When using paper prescription pads, secure the supply from theft at all times When preparing medications for administration, check medication three times before administering 38

Role of the Medical Assistant in Preventing Liability Suits Paramount importance to both you and your employer In many cases, you are only one who will hear patient's complaint Ability to handle complaint professionally and efficiently may eliminate potential lawsuit for physician Act under a code of ethics 39

Role of the Medical Assistant in Preventing Liability Suits Office Management Treat all patients with same courtesy and dignity you would expect to receive Log and return telephone calls promptly Explain any delays to patients who are waiting to see physician Offer to set up another appointment if delay will be very long 40

Role of the Medical Assistant in Preventing Liability Suits Office Management Never make promises regarding what physician can do for patient Carefully explain all fees and responsibilities for bills to patient and relate any concerns patient may have to physician Relay any dissatisfied patient comments to physician and practice manager 41

Role of the Medical Assistant in Preventing Liability Suits Office Management If physician will be out of town or absent from office, post dates and include announcement in monthly billing envelopes Provide name and telephone number of physician available for patients who need care when their own physician is absent 42

Role of the Medical Assistant in Preventing Liability Suits Office Management If physician is withdrawing from a case, send letter informing patient Patient must be provided time frame, stated in letter, in which to locate new medical provider Send letter certified mail with return receipt requested Keep a copy of letter and return receipt with patient's record 43

Role of the Medical Assistant in Preventing Liability Suits Documentation Carefully sign or initial every note If patient did not keep an appointment, be sure to document the fact as a no-show Follow up to determine why patient missed the appointment 44

Role of the Medical Assistant in Preventing Liability Suits Documentation Document when a patient is referred to another physician Follow up to make sure patient did see referral physician 45

Role of the Medical Assistant in Preventing Liability Suits Documentation Document all patient contracts, including telephone prescription refills and tests and procedures that have been ordered Call all patients the day after surgery to check on their progress and document this call 46

Role of the Medical Assistant in Preventing Liability Suits Documentation Record all care and treatment given as soon as possible after patient's visit Be sure physician reviews and initials all diagnostic reports in a timely fashion before they are filed Provide all patient instructions in writing 47

Role of the Medical Assistant in Preventing Liability Suits Certification and Licensing Have thorough understanding of limits of certification and standards of care for your profession Never perform any procedures for which you are not trained or qualified Do not diagnose or prescribe drugs over the telephone (even OTC drugs) 48

Role of the Medical Assistant in Preventing Liability Suits Certification and Licensing Do not call yourself a nurse or allow anyone else to refer to you as one Participate in continuing education and training programs to maintain your skill levels 49

Role of the Medical Assistant in Preventing Liability Suits Safety Maintain safe environment in office or work site for patients and staff Handle requests for maintenance repairs Report any safety hazards at once 50

Role of the Medical Assistant in Preventing Liability Suits Safety Carefully check and document medical waste disposal Be concerned about safety of maintenance personnel who must handle the waste containers 51

Role of the Medical Assistant in Preventing Liability Suits Safety Always correctly dispose of syringes and needles as well as contaminated medical waste in designated hazardous waste containers Carefully maintain and document quality checks on laboratory testing equipment 52

Questions? 53