Medical Ethics and Documentation Quiz

Patient/Physician Relationship

• Proper treatment demands truthfulness from the patient.
• Withholding crucial information can lead to severe consequences.
• Physicians are not liable if patients don't share critical information.

Physician Rights

• Physicians have the right to select patients.
• They can refuse to treat certain patients.
• They control the services offered, office location, and hours.
• They expect payment for services.
• They can take vacations/time off.

Patient Rights

• Patients have the right to consent to treatment.
• They expect a proper standard of care.
• Confidentiality is a patient right.

Patient Obligations

• Patients are expected to follow physicians' instructions.
• Patients are responsible for paying for medical services.

The Patient Care Partnership (Patient's Bill of Rights)

• Details what patients should expect during a hospital stay.
• These expectations include high-quality care, a clean and safe environment, patient involvement, protection of privacy, assistance leaving the hospital, and help with billing claims.
• Medical assistants should discuss these rights with patients before hospitalization.

Informed Consent

• The doctrine of informed consent involves several key components:
  • Explaining the treatment's advantages and risks to patients
  • Offering alternatives to the patient
  • Outlining potential outcomes of the treatment
  • Identifying what might happen without treatment
  • Using understandable language.
• Review the informed consent form given in the textbook, and evaluate whether it meets the requirements.

Informed Consent and Shared Decision Making

• Informed consent plus informed choice involves identifying patient needs, values, and goals.
• Discuss treatment uncertainties, provider experience, costs, and create a two-way conversation where patients/families are involved in decisions.
• Further, ensure the patient understands the risks and benefits of their decisions.
• Informed choice is contingent on informed consent.
• Review the importance of nature of treatment, risks, benefits, alternatives, and questions in the consent process.

Considerations Regarding Informed Consent

• Barriers to informed consent may include:
  • Language difficulties
  • Hearing impairments
  • Visual impairments
  • Religious beliefs
  • Misconceptions or false expectations.
• Medical assistants should bear in mind the potential effect of these factors on informed consent.

Medical Assistant's Responsibility with Informed Consent

• It's the medical assistant's responsibility to ensure a signed consent form is obtained and placed in the patient's chart.
• Parent/guardian signatures are needed for procedures on minors (except in emergencies).

Rights of Minors

• A minor is someone under the age of majority (usually 18, but this can differ by state).
• Most states don't let minors consent to treatment; however, there are exceptions.
• Exceptions include pregnancy, birth control information, testing/treatment for sexually transmitted diseases, substance abuse, and psychiatric care.

Emancipated Minors

• Emancipated minors meet certain conditions.
• These conditions include:
  • Living independently
  • Being married
  • Self-supporting
  • Serving in the armed forces

Patient Self-Determination Act

• This act empowers patients to have a voice in their health care decisions.
• It's also referred to as "My Voice-My Choice."

Living Will

• Patients in a living will request that life-sustaining treatments or nutritional support are not used to prolong their lives.

Durable Power of Attorney

• The Durable Power of Attorney (DPOA) allows an agent or representative to act on behalf of the patient — this is also known as DOPA.

Uniform Anatomical Gift Act

• This act pertains to organ donation.
• Persons 18 years or older and of sound mind can be organ donors.
• The physician performing the transplant cannot be the same physician who determines the person's death or time of death.
• Money cannot be exchanged for organ donation.
• Donation is indicated by a card or driver's license.
• If the decision wasn't made before death, the family can make the decision for the donor.

Critical Thinking Questions; DPOA

• Discuss the implications of not having a DPOA. Considerations include:
  • Establishing DPOA is inexpensive.
  • The patient decides who makes healthcare decisions.
  • Agent's power is controlled by the patient (general/specific).
  • The document can stipulate agent’s obligations (being bonded, accounting for transactions).
• Discuss any disadvantages associated with having a DPOA:
  • Patient's competence at the time of writing may be questioned later.
  • Specific forms may be required by financial institutions.
  • Some institutions may not recognize DPOA after a set time period.
  • A DPOA could become abusive depending on its stipulations.
  • Agent could be untrustworthy.

Critical Thinking Questions; Organ Donation

• Explore the possible disagreements surrounding organ donation:
  • Individuals may avoid becoming donors due to fears of their own medical treatment being negatively affected.
  • There is a misconception that medical professionals are less likely to focus on a donor's medical needs.
  • The medical professionals involved in donation processes may be different to those in the primary setting.
  • Ultimately, individuals may not view one life as being any more important than another.

Documentation; Who/What

• Medical records must document the following:
  • Telephone calls
  • Patient visits
  • Treatments
  • Medications
  • No-shows
  • Appointment cancellations
  • Prescription refills
  • Vital signs.

If it is not recorded, then it did not happen.

Case Scenarios; Medical Negligence

• Scenario context: Parents filed a medical negligence lawsuit against the hospital due to the death of their child.
• The child had a heart defect that required surgery, which resulted in cardiac dysrhythmias.
• Digoxin was prescribed for dysrhythmias.
• The hospital's system for administering digoxin was controlled by security for high-risk medications requiring user names/passwords.
• The child received an incorrect dosage of digoxin (225 mg instead of 450 mcg) which caused a life-threatening event due to the elevated potassium levels.
• The case centers on documentation errors and a failure to properly monitor the child's condition.
• The nurse's testimony and hospital policy about double-checking medication dosages were key elements in the case.

Litigation and Subpoenas

• Litigation is the legal term for a lawsuit tried in a court.
• When involved in litigation, a subpoena for medical records may be issued. Only the requested information should be provided.

Court Testimony

• Being professional, calm, dignified, and serious is essential during court testimony.
• Avoid answering questions you don't understand.
• Only factual information should be presented.
• Avoid memorizing testimony but always tell the truth.

Public Duties of Physicians

• Certain reporting requirements exist for physicians:
  • Births, stillbirths, and deaths
  • Communicable illnesses
  • Drug abuse incidents
  • Specific injuries such as gunshot, knife wounds, and animal bites must be reported.

Drug Regulations

• FDA (Food and Drug Administration) controls the testing and approval of drugs for public use.
• DEA (Drug Enforcement Administration) regulates the sale and use of controlled medications.
• Physicians must have a DEA registration number to purchase ,administer, dispense, or prescribe controlled medications.
• Controlled drugs are kept in a double-locked cabinet.

Medical Assistants

• Assistants administer medications under a physician's direct supervision (following state regulations).
• Secure all prescription pads.
• Double-check medication doses three times before administration:
• Checking medications on the shelf.
• Checking the name & dosage before prep.
• Checking the label again before placing back on the shelf.

Office Management

• Treat patients with courtesy and dignity.
• Respond to returned phone calls, explaining delays.
• Never make promises related to treatment.
• Thoroughly explain patient costs and responsibilities.
• Relay patient dissatisfaction to office/physician.
• Inform patients of appropriate contacts if the physician is not available.
• Provide written documentation for patient withdrawals from the care (e.g., certified letter or notes in patient chart).

Documentation-Must Do's

• Sign or initial every note.
• Follow up with patients concerning no-shows.
• Manage referrals/contacts with other physicians through appropriate methods (calls, etc.).
• Manage all patient contacts.
• Document all care/treatment rendered to patients.
• Have physicians review and initial all diagnostic reports.
• Provide written instructions to the patient
• Ensure SOAP notes are complete and accurate.

SOAP Notes

• SOAP Notes: A standardized format for documenting patient encounters.
• S (Subjective): Patient complaints/symptoms, reported by the patient or others.
• O (Objective): Measurable observations (e.g., vital signs, physical findings, lab results).
• A (Assessment): Clinical judgment/diagnosis of the patient's condition.
• P (Plan): Health care provider's plan of action, including medications, lab tests, treatments planned, and referrals if necessary.

Mobile Medical Assistant.NET (Medical Assistant, Net Mobile Site)

• This Mobile Medical Assistant allows for brief patient interviews, documenting subjective information, vital signs, and other relevant information about patients. - However it should be clearly stated that the medical assistant is not authorized to fill out the assessment or plan portions of a SOAP note.

Legal Issues

• Tampering with medical records involves actions like:
  • Adding to an existing record without proper notations.
  • Placing inaccurate information into the record.
  • Omitting significant facts.
  • Dating a record to make it appear written earlier.
  • Rewriting or altering the record .
  • Destroying records.
  • Adding to a fellow colleague/assistant's notes without permission.

MA Certification and Licensing

• MA's must understand their certified limits and standards of care.
• MA's should not attempt to diagnose or prescribe.
• MA's should not refer to themselves as a nurse.
• MA's should participate in continuing education and training.

Practice, Practice, Practice; Informed Consent

• Key criteria for informed consent should be:
  • Explanation of advantages/risks of the treatment
  • Availability of alternatives to the treatment
  • Potential outcomes related to treatment
  • Possible results of not having treatment
  • Clear and understandable language.

Practice, Practice, Practice; Tampering

• Tampering Actions:
  • Adding to the existing medical record without proper date/time/initials.
  • Reporting inaccurate information.
  • Omitting important medical facts..
  • Falsely documenting/altering a medical note.
  • Destroying medical records.
  • Adding information to another individual/assistant's medical record without permission.

Practice, Practice, Practice (Amendments)

• Correct method of amending a medical note: Adding to an existing medical record with correct date/time/initials on a new document entry is the amendment process.