1. 3
Medical Law and Ethics
Lesson 3:
Documentation and Regulations

2. 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

3. 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

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

5. Documentation Calls Visits Treatments No-shows
Appointment cancellations 5

6. Documentation Medications Prescription refills Vital signs
Other pertinent information 6

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

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

18. 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

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

20. 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

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

22. 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

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

24. 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

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

26. 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

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

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

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

30. 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

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

32. 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

33. 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

34. 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

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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. Questions? 53