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.

Test your knowledge on medical ethics, proper documentation, and the responsibilities of healthcare professionals. This quiz covers vital concepts such as DPOA, living wills, SOAP notes, and the role of medical assistants. Understand the implications of medical record handling and patient self-determination documents.