Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Pearson's Comprehensive Medical Assisting Administrative and Clinical Competencies Second Edition CHAPTERCHAPTER CHAPTER 3 3 Medical Law and Ethics Lesson 3: Documentation and Regulations

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan 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.

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Documentation It is critical to carefully document what happens in the medical office. If an action is not recorded on the medical chart, then it is considered by the court not to have been performed.

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Questions 1.Why is documentation so important? 2.Give some examples.

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Information Documented in a Patient’s Chart Calls and visits Treatments No-shows Appointment cancellations Medications Prescription refills Vital signs Other pertinent information

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan When a Medical Record is Subpoenaed for Court Copy only the parts of the record that are requested and sent Send a certified copy unless the original record is subpoenaed If original is subpoenaed, make a copy and return copy to file Place a receipt for the subpoenaed record in the patient’s file Notify the patient by certified mail that the records have been subpoenaed

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Cautions with Documentation Be careful with fax transmissions of medical records – avoid it Receiving fax must be located in a restricted area A disclaimer should be placed on the fax cover explaining that records are confidential

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Court Testimony Information is gained from a witness by: –Interrogation by an attorney (interview) –Submission of a deposition (written documentation of an oral statement in front of a court officer) –Testifying in court Expert witness –Testifies about standard of care –Typically a physician

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Court Testimony If you are asked to testify in court… –Be professional –Remain calm, dignified, and serious –Always tell the truth –Do not answer questions you do not understand –Do not memorize your testimony ahead of time –Just present the facts about the case

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Reports Physicians Must Provide Births Stillbirths Deaths Communicable illnesses or diseases Drug abuse Certain injuries Abuse of child and adults Gunshot and knife wounds Animal bites

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Birth Certificate Physicians have a duty to issue a legal certificate of birth Used as a legal proof of age Required for many benefits and documents: –Social security –Passport –Driver’s license

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Death Certificate Physicians have a duty to issue a legal certificate of death for natural deaths Each state has specific requirements A coroner or health official will have to sign a death 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

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.What is the purpose of a death certificate?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Reportable Communicable Diseases Physicians have a duty to report all diseases that can be transmitted from one person to another and are considered a general threat to the public Each state has specific reporting requirements Physicians can either mail or phone in the report

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.Why is the reporting of communicable diseases necessary and required?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Childhood Vaccines and Toxoids Required by Law 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

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.Why might the government require childhood vaccines?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Reportable Injuries Physicians have a duty to report certain injuries Requirements differ by state Injuries include: –Gun or knife wounds –Rape and battered persons injuries –Spousal abuse –Child abuse –Elder abuse

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.Why is the reporting of injuries necessary and required?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Child Abuse Physicians have a duty to report questionable injuries of children Requirements differ by state These injuries include: –Bruises –Fractured bones –Burns –Malnutrition –Poor growth –Lack of hygiene

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question Why is the reporting of child abuse necessary and required?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Elder Abuse Physicians have a duty to report questionable injuries of the elderly These requirements include: –Physical abuse –Neglect –Abandonment Requirements differ by state

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.Why is this reporting of elder abuse necessary and required?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Drug Abuse Abuse of prescription drugs must be reported Abuse may be difficult to determine since a patient may go to several different doctors for the same drug A physician should always see the patient before prescribing drugs

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan To visit these organizations go online to: and Drug Regulation Agencies Food and Drug Administration (FDA) –Federal agency –Has jurisdiction over testing and approving drugs for public use Drug Enforcement Administration (DEA) –Branch of the Justice Department –Regulates the sale and use of schedule drugs

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Click here to see more detail or visit What the FDA Regulates Biological products Cosmetics Drugs Foods Medical devices Radiation-emitting electronic products Veterinary products

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan What the FDA Does Not Regulate Advertising Alcohol Consumer products Drugs of abuse Health insurance Meat and poultry Pesticides Restaurants and grocery stores Water

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.Who regulates each of these areas not regulated by the FDA?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan The DEA Has the responsibility of enforcing controlled substances laws and regulations Provides many resources and services: –Drug information –Drug photos –DEA Most-wanted fugitive list –Threat assessment information

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan To watch an example of drug prevention related to DXM prevention click here or visit Other Resources and Services of the DEA Stats and facts Criminal cases against doctors Drug prevention programs

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Form DEA 224 Used by physicians to register with the DEA Allows physicians to prescribe, dispense, or administer controlled substances Renewal is required every 3 years

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Requirements for Controlled Substances Controlled drugs must be kept in a double- locked cabinet Any theft must be immediately reported to both regional DEA office and local police Physician’s black bag and prescription blanks should always be stored in a secure, locked location

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Requirements for Controlled Substances Records Records must be kept to document the administering and dispensing of controlled drugs Federal regulations require a written inventory in triplicate of drug supplies –Inventory is based on daily use –Required every 2 years –Required to be kept for two more years

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Schedule for Controlled Substances Schedule I –Highest potential for addiction and abuse Schedule II –High potential for addiction and abuse Schedule III –Moderate to low potential for addiction and abuse Schedule IV –Lower potential than Schedule III drugs Schedule V –Low potential for addiction and abuse

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Common Controlled Substances Anabolic steroids Butabarbital Chloral hydrate Cocaine Codeine Diazepam Heroin LSD Marijuana Morphine Opium Phenobarbital Secobarbital Tylenol with codeine

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Role of the Medical Assistant Does not dispense controlled substances Must be knowledgeable about the regulations governing the documentation and control of the drugs Only licensed personnel are permitted to dispense drugs Always report any unusual patient behavior indicating addictive drug use

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.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? 2.You come to work one day and notice that the lock for the controlled substance cabinet has been tampered with. What do you do?

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Role of the Medical Assistant Critical in preventing liability suits Sometimes the only person who hears a patient’s complaint or issue Needs to know how to handle situations in a professional and efficient manner Responsible for always acting within the Code of Ethics

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Ways to Help Your Employer Follow the chain of command Report to your immediate supervisor any negligent action you observe If you make an error, bring it to your supervisor’s attention immediately so that it can be corrected

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan If you are aware of illegal activity and remain silent, you may be liable. MA’s Role Related to Confidentiality/Privacy Issues Never make any statements about your employer that could be interpreted as an admission of fault Do not remain silent if you are aware that your employer is doing something illegal Do not participate in negative or critical discussions of the physician with patients

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Confidentiality/Privacy Issues Do not comment on a patient’s negative criticism of a current or former physician Never discuss anything about the patient outside of the office Make sure that a female MA is present when the physician (male or female) examines a female patient Treat all patients with dignity and respect

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Office Management Treat all patients with the 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 the physician Offer to set up another appointment if the delay will be very long

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Office Management Never make promises regarding what the physician can do for the patient Carefully explain all fees and responsibilities for bills to the patient Relay any concerns about bills from the patient to the physician Relay any dissatisfied patient comments to the physician

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Office Management If the physician will be out of town or absent from the office, post these dates and include an announcement in the monthly billing envelopes Provide the name and telephone number of the physician available for patients who need care when their own physician is absent

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan A physician can be brought up on charges of abandonment if there is no documentation or evidence that there was a formal withdrawal. MA’s Role Related to Office Management If the physician is withdrawing from a case, then send a letter informing the patient Send the letter via certified mail with return receipt requested Keep a copy of the letter and receipt with the patient’s record

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Medical documents are legal documents and may be used in a court of law. MA’s Role Related to Documentation Carefully sign or initial every note If the patient did not keep an appointment, be sure to document the fact as a no-show Follow up to determine why the patient missed the appointment Document when a patient is referred to another physician Follow up to make sure the patient did see the referral physician

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to 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

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Documentation Record all care and treatment given as soon as possible after the patient’s visit Be sure the physician sees and initials all diagnostic reports in a timely fashion before they are filed Provide all patient instructions in writing

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Drug Regulations May administer medication only under the direct supervision of a physician Follow the Controlled Substances Act by carefully following procedures and documenting actions Know state laws Secure the supply of prescription pads from theft at all times

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Drug Regulations When preparing medications for administration, check the medication three times: –Before removing it from the shelf –Again, before preparing the dosage –Before returning the medication to the shelf

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Continue your education and training to maintain your skill levels. MA’s Role Related to Certification and Licensing Know the 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) Do not call yourself a “nurse” or allow anyone else to refer to you as one

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan File signed informed consents immediately! MA’s Role Related to Informed Consent Physician must thoroughly explain all procedures to the patient MA is responsible for making sure there is a signed consent form Never have a patient sign a document that he or she does not understand Obtain a parent/guardian’s signature before providing care to a minor except in the case of an emergency

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan If you knowingly overlook a hazard you could be found guilty of negligence! Remove needle from syringe and dispose of in sharps container. MA’s Role Related to Safety Issues Maintain a safe environment in the office for the patients and staff Handle requests for maintenance repairs Report any safety hazards at once

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan MA’s Role Related to Safety Issues Carefully check and document medical waste disposal Be concerned about the safety of maintenance personnel who must handle waste containers Always dispose of syringes and needles correctly in designated hazardous waste containers Maintain and document careful quality checks on laboratory testing equipment

Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Questions?