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Questions and Answers
What is the primary purpose of the Patient's Bill of Rights?
What is the primary purpose of the Patient's Bill of Rights?
The Employee Retirement Income Security Act (ERISA) is one of the common laws and regulations affecting medical practices and patient care.
The Employee Retirement Income Security Act (ERISA) is one of the common laws and regulations affecting medical practices and patient care.
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What is the purpose of the No Surprise Act?
What is the purpose of the No Surprise Act?
HIPAA gives patients the right to their health care information.
HIPAA gives patients the right to their health care information.
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Which of the following are types of abuse? (Select all that apply)
Which of the following are types of abuse? (Select all that apply)
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Negligence in the health care setting requires a specific intent to harm someone.
Negligence in the health care setting requires a specific intent to harm someone.
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Which principle of ethics emphasizes doing what is best for patients, considering their pain, suffering, and quality of life?
Which principle of ethics emphasizes doing what is best for patients, considering their pain, suffering, and quality of life?
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Biases can have both negative and positive consequences.
Biases can have both negative and positive consequences.
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Who owns the medical records in a healthcare facility?
Who owns the medical records in a healthcare facility?
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What type of safeguards refer to the policies and procedures documented in writing?
What type of safeguards refer to the policies and procedures documented in writing?
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What type of consent is required when sharing health care information?
What type of consent is required when sharing health care information?
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What type of safeguards refer to the physical monitoring and access to PHI?
What type of safeguards refer to the physical monitoring and access to PHI?
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Who has the right to access a patient's medical records?
Who has the right to access a patient's medical records?
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What type of safeguards refer to the responsibility of the healthcare provider to monitor and safeguard patient information through technology-related items?
What type of safeguards refer to the responsibility of the healthcare provider to monitor and safeguard patient information through technology-related items?
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Who owns the actual medical record?
Who owns the actual medical record?
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What is required to release medical records to another health care provider?
What is required to release medical records to another health care provider?
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What is an exception to releasing medical records without the patient's authorization?
What is an exception to releasing medical records without the patient's authorization?
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Who has the right to access the patient's medical record?
Who has the right to access the patient's medical record?
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What is the purpose of a signed release form?
What is the purpose of a signed release form?
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What is the term for when the court orders someone to appear in court and bring records with them?
What is the term for when the court orders someone to appear in court and bring records with them?
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What is the main goal of HIPAA regarding patient information?
What is the main goal of HIPAA regarding patient information?
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Who has the right to access and control their medical records?
Who has the right to access and control their medical records?
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What is the primary purpose of the Good Samaritan Acts?
What is the primary purpose of the Good Samaritan Acts?
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What type of safeguards are implemented to protect electronic health records?
What type of safeguards are implemented to protect electronic health records?
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What law prohibits discrimination on the basis of genetic information?
What law prohibits discrimination on the basis of genetic information?
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What is the primary purpose of the Patient Safety and Quality Improvement Act (PSQIA)?
What is the primary purpose of the Patient Safety and Quality Improvement Act (PSQIA)?
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What is the primary purpose of the Anti-Kickback Statute (AKBS)?
What is the primary purpose of the Anti-Kickback Statute (AKBS)?
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What is the main purpose of training in proper documentation and maintenance of medical records?
What is the main purpose of training in proper documentation and maintenance of medical records?
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What is the main purpose of the HIPAA Security Rule?
What is the main purpose of the HIPAA Security Rule?
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Who is considered the owner of the medical records?
Who is considered the owner of the medical records?
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What type of safeguards refer to the physical monitoring and access to PHI?
What type of safeguards refer to the physical monitoring and access to PHI?
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When is written consent required under HIPAA?
When is written consent required under HIPAA?
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Who has the right to access a patient's medical records?
Who has the right to access a patient's medical records?
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What is the purpose of a signed release form?
What is the purpose of a signed release form?
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What right does the patient have regarding their medical records under HIPAA?
What right does the patient have regarding their medical records under HIPAA?
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What is the purpose of a signed release form?
What is the purpose of a signed release form?
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What type of safeguard is responsible for protecting patient information through technology-related items?
What type of safeguard is responsible for protecting patient information through technology-related items?
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Who has the right to access a patient's medical record, besides the patient?
Who has the right to access a patient's medical record, besides the patient?
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What is an exception to releasing medical records without the patient's authorization?
What is an exception to releasing medical records without the patient's authorization?
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What is the main goal of HIPAA regarding patient information?
What is the main goal of HIPAA regarding patient information?
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Who owns the medical records in a healthcare facility?
Who owns the medical records in a healthcare facility?
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What type of consent is required when sharing health care information?
What type of consent is required when sharing health care information?
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What type of safeguards refer to the policies and procedures documented in writing?
What type of safeguards refer to the policies and procedures documented in writing?
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What is required to release medical records to another health care provider?
What is required to release medical records to another health care provider?
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Who has the right to access a patient's medical records?
Who has the right to access a patient's medical records?
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What type of safeguards refer to the physical monitoring and access to PHI?
What type of safeguards refer to the physical monitoring and access to PHI?
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What is the primary purpose of a signed release form?
What is the primary purpose of a signed release form?
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What is the main goal of HIPAA regarding patient information?
What is the main goal of HIPAA regarding patient information?
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Who is considered the owner of the medical records?
Who is considered the owner of the medical records?
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What type of consent is required when sharing health care information?
What type of consent is required when sharing health care information?
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What type of safeguards refer to the policies and procedures documented in writing?
What type of safeguards refer to the policies and procedures documented in writing?
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Who has the right to access a patient's medical records?
Who has the right to access a patient's medical records?
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What is the primary purpose of a signed release form?
What is the primary purpose of a signed release form?
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What is the main goal of HIPAA regarding patient information?
What is the main goal of HIPAA regarding patient information?
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Who has the ownership of the actual medical record?
Who has the ownership of the actual medical record?
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What is the purpose of a signed release form?
What is the purpose of a signed release form?
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What type of safeguard is responsible for protecting patient information through technology-related items?
What type of safeguard is responsible for protecting patient information through technology-related items?
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Who has the right to access a patient's medical record?
Who has the right to access a patient's medical record?
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What is an exception to releasing medical records without the patient's authorization?
What is an exception to releasing medical records without the patient's authorization?
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What is the main goal of HIPAA regarding patient information?
What is the main goal of HIPAA regarding patient information?
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Who is responsible for ensuring informed consent is obtained from the patient?
Who is responsible for ensuring informed consent is obtained from the patient?
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What type of consent is implied when a patient responds to a medical assistant's question about taking their temperature?
What type of consent is implied when a patient responds to a medical assistant's question about taking their temperature?
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What is the primary purpose of technical safeguards under HIPAA?
What is the primary purpose of technical safeguards under HIPAA?
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Who has the right to access a patient's medical records?
Who has the right to access a patient's medical records?
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What is the purpose of a signed release form?
What is the purpose of a signed release form?
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What type of consent is required when sharing healthcare information?
What type of consent is required when sharing healthcare information?
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What is the primary goal of HIPAA regarding patient information?
What is the primary goal of HIPAA regarding patient information?
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Who owns the medical records in a healthcare facility?
Who owns the medical records in a healthcare facility?
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Patients have the right to control their medical records under HIPAA.
Patients have the right to control their medical records under HIPAA.
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The HIPAA Security Rule is primarily focused on physical safeguards.
The HIPAA Security Rule is primarily focused on physical safeguards.
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Written consent is required for all disclosures of medical records under HIPAA.
Written consent is required for all disclosures of medical records under HIPAA.
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Health care providers are responsible for implementing administrative safeguards to protect patient information.
Health care providers are responsible for implementing administrative safeguards to protect patient information.
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A signed release form is required for all disclosures of medical records.
A signed release form is required for all disclosures of medical records.
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The medical provider owns the information or data found within the medical record.
The medical provider owns the information or data found within the medical record.
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Only healthcare providers have access to a patient's medical records.
Only healthcare providers have access to a patient's medical records.
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A signed release form is required for a patient to access their own medical records.
A signed release form is required for a patient to access their own medical records.
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Healthcare staff can access a patient's medical record without their consent.
Healthcare staff can access a patient's medical record without their consent.
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The court can order the release of medical records with a subpoena.
The court can order the release of medical records with a subpoena.
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A patient can request the release of their medical records to anyone without a signed release form.
A patient can request the release of their medical records to anyone without a signed release form.
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Healthcare providers can release medical records without a patient's consent in cases of criminal acts.
Healthcare providers can release medical records without a patient's consent in cases of criminal acts.
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Medical records can be released without a patient's authorization in cases of communicable diseases.
Medical records can be released without a patient's authorization in cases of communicable diseases.
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Implied consent is given through oral or written words.
Implied consent is given through oral or written words.
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Informed consent ensures the patient knows and understands the treatment but does not require acceptance.
Informed consent ensures the patient knows and understands the treatment but does not require acceptance.
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HIPAA gives patients the right to access and control their medical records.
HIPAA gives patients the right to access and control their medical records.
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Technical safeguards refer to the physical monitoring and access to PHI.
Technical safeguards refer to the physical monitoring and access to PHI.
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A signed release form is required for release of medical records to another healthcare provider.
A signed release form is required for release of medical records to another healthcare provider.
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Administrative safeguards refer to the physical monitoring and access to PHI.
Administrative safeguards refer to the physical monitoring and access to PHI.
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Medical records are owned by the healthcare facility.
Medical records are owned by the healthcare facility.
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Study Notes
Medical Law and Ethics
- Medical professionals, including medical assistants, have a primary responsibility to provide high-quality patient care and respect patient privacy and confidentiality.
- They are bound by various laws and regulations and have legal and ethical responsibilities to patients, employers, and society.
Patient's Bill of Rights
- The Patient's Bill of Rights was created by the American Hospital Association (AHA) in 1973 to ensure patient protection and safety.
- The bill outlines 15 guarantees for patients seeking medical care, including:
- The right to be treated fairly and respectfully
- The right to receive information about diagnosis, treatment, and prognosis
- The right to make decisions about care before and during treatment
- The right to privacy and confidentiality in medical exams and records
Laws and Regulations
- Patient Protection and Affordable Care Act (ACA) of 2010:
- Expands access to affordable, quality health insurance
- Emphasizes prevention and wellness
- Curbs rising health care costs
- Health Insurance Portability and Accountability Act (HIPAA) of 1996:
- Gives patients rights over their health information
- Sets rules and limits on who can access patient information
- Health Information Technology for Economic and Clinical Health (HITECH) Act:
- Expands on HIPAA to include provisions for electronic transmission of patient information
- Prohibits the sale of protected health information (PHI)
- Other laws and regulations:
- Occupational Safety and Health (OSH) Act
- Controlled Substances Act (CSA)
- Emergency Medical Treatment and Active Labor Act (EMTALA)
- Clinical Laboratory Improvement Act (CLIA)
- Title VII of Civil Rights Act of 1964
- Americans with Disabilities Act of 1990 (ADA)
- Genetic Information Nondiscrimination Act of 2008 (GINA)
- Patient Safety and Quality Improvement Act (PSOIA)
- Anti-Kick Back Statute (AKBS)
- No Surprise Act (NSA)
Protecting Patient Privacy and Confidentiality
- Legal Requirements for Maintenance, Storage, and Disposal of Records:
- HIPAA outlines patient privacy and confidentiality
- Patients have the right to receive a copy of their medical records
- Providers must adhere to HIPAA
- Employers are not considered covered entities
- Sharing Information and Release of Information:
- Providers must obtain written consent before sharing patient information
- Patients have the right to access their medical records
- Exceptions to release of information include criminal acts, legally ordered disclosures, and communicable diseases
Informed and Implied Consent
- Consent is an act of reason, requiring mental capacity and possession of essential information
- Types of consent:
- Implied consent: inferred based on patient actions or conduct
- Expressed consent: given orally or in writing
- Informed consent: a process ensuring the patient knows and understands the treatment and its consequences### Patient Autonomy and Consent
- Patient autonomy is a critical aspect of healthcare, protecting patients' legal rights and guiding ethical healthcare practices.
- Healthcare providers must obtain informed consent from patients, detailing all possible risks, benefits, and alternatives of a treatment or procedure.
- Failure to obtain informed consent may lead to medical negligence and malpractice cases.
Advance Directives
- Advance directives are legal documents that outline a patient's wishes for end-of-life care, such as:
- Living will: specifies medical treatments the patient wants or doesn't want, and under what conditions.
- Durable power of attorney (DPOA): appoints a healthcare agent to make medical decisions on the patient's behalf.
- Advance directives are legally valid throughout the US and remain in effect until officially changed.
- Healthcare providers must obtain, review, and comply with advance directives.
Do Not Resuscitate (DNR) Orders
- A DNR order is a legal document that communicates a patient's wish to not receive CPR or advanced cardiac life support if their heart stops or they stop breathing.
- DNR orders do not affect other treatments, such as chemotherapy, antibiotics, or dialysis.
Physician Orders for Life-Sustaining Treatment (POLST)
- POLST is a type of advance directive that outlines a patient's wishes for end-of-life care, particularly for those with advanced or terminal illnesses.
- POLST forms involve a shared decision-making process between the healthcare provider and patient.
- POLST forms are portable, meaning they move with the patient to different healthcare providers and settings.
Legal Requirements for Reportable Violations or Incidents
- Healthcare professionals are bound by laws and regulations, including criminal and civil laws, to protect patients and themselves.
- Criminal law violations may result in fines, imprisonment, or capital punishment.
- Civil law violations may result in civil lawsuits, with penalties including monetary damages.
Mandated Reporting
- Healthcare professionals are required to report incidents of concern, such as:
- Births and deaths
- Communicable diseases
- Assaults or criminal acts
- Abuse, neglect, and exploitation
- Reporting is mandatory to protect the public and vulnerable populations.
Abuse
- Abuse is a misuse or maltreatment, including physical, verbal, psychological, sexual, and economic forms.
- Mandated reporting laws require healthcare professionals to report suspected abuse to appropriate agencies.
Ethics and Values
- Ethics are the rules, standards, and moral principles that govern a person's behavior.
- Medical ethics focuses on the moral principles and judgments that healthcare professionals use to determine right and wrong in healthcare.
- The basic principles of medical ethics include:
- Autonomy: respecting patients' decision-making capacity.
- Justice: ensuring fairness and consistency in healthcare.### Health Care Justice
- Evaluating justice in healthcare involves considering four main areas: fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation.
- Justice is about ensuring equal treatment and fair distribution of benefits, risks, resources, and costs.
Beneficence
- Beneficence is the principle of doing the "most good" or doing what is best for patients.
- It involves considering patients' pain, physical and mental suffering, risk of disability and death, and quality of life.
Nonmaleficence
- Nonmaleficence is the principle of "do no harm" to the patient or to the fewest number of people in society.
- It is difficult to apply successfully due to the risks and adverse effects associated with most treatments.
Cultural Competence
- Healthcare providers must create and deliver culturally competent patient care to meet the needs of patients from diverse backgrounds.
- Cultural competence involves understanding and appreciating different cultures, establishing relationships, and building strong alliances with diverse groups.
- Culture is a strong part of people's lives, influencing their views, values, humor, hopes, loyalties, and fears.
Biases
- Biases can be conscious or unconscious and can negatively impact multicultural acceptance and inclusion in healthcare.
- Biases can exist towards any social group, including age, sex, gender identity, physical abilities, religion, sexual orientation, and many other characteristics.
- Confronting one's own biases and prejudice is a crucial step towards building multicultural competence.
Healthcare Laws and Guidelines
- Various laws and guidelines regulate healthcare, including the Americans with Disabilities Act, Anti-Kickback Statute, Clinical Laboratory Improvement Act, and more.
- These laws and guidelines aim to protect patients, healthcare providers, and employers from negligence, malpractice, and discrimination.
Key Terms
- Advance directives: written statements of a person's wishes regarding medical treatment.
- Autonomy: the capacity to think, decide, and act on one's own free will and initiative.
- Durable power of attorney: a legal document naming a healthcare agent or proxy to make medical decisions for patients.
- Emergency Medical Treatment and Active Labor Act: a law requiring hospitals to provide appropriate medical screening to patients seeking treatment.
- Health Insurance Portability and Accountability Act: a federal law protecting sensitive patient health information from disclosure without consent.
Patient Rights and HIPAA
- Patients have the right to inspect, review, and receive a copy of their medical records and billing records held by health plans and health care providers.
- Patients own the information or data within the medical record, while the health care provider or facility owns the actual medical record.
Exceptions to Patient Authorization
- Criminal acts: evidence used in abuse cases, stabbings, gunshot wounds, or sexual assaults
- Legally ordered: court-ordered medical records submission as evidence in a court case (subpoena)
HIPAA Requirements
- Covered entities (health insurance companies, clearinghouses, providers) must adhere to HIPAA
- Employers are not considered covered entities
- HIPAA Security Rule: implement reasonable and suitable safeguards to protect protected health information and prevent breaches of confidentiality
- HIPAA requires explanation of patient rights and written consent when sharing health care information
- Patients must sign a form indicating receipt of a privacy notice from a health care provider or hospital
HIPAA Safeguards
- Administrative safeguards: written policies and procedures for HIPAA compliance
- Physical safeguards: physical monitoring and access to protected health information (PHI)
- Technical safeguards: monitoring and safeguarding patient information through technology-related items
Patient Data Ownership
- Patients own the information within the medical record, but the health care provider owns the medical record
- Medical records are legal documents that must remain with the health care facility
Good Samaritan Acts
- Allow bystanders to get involved in emergency situations without fear of liability
Genetic Information Nondiscrimination Act of 2008 (GINA)
- Prohibits discrimination on the basis of genetic information with respect to health insurance and employment
Patient Safety and Quality Improvement Act (PSOIA)
- Framework for gathering and analyzing information regarding patient safety within protected health information laws
Anti-Kick Back Statute (AKBS)
- Criminal law that prohibits receiving benefits for referral or business involving federal health care programs
No Surprise Act (NSA)
- Protects individuals from surprise billing for emergency services from an out-of-network provider or facility without prior authorization
Patient Rights and HIPAA
- Patients have the right to inspect, review, and receive a copy of their medical records and billing records held by health plans and health care providers.
- Patients own the information or data within the medical record, while the health care provider or facility owns the actual medical record.
Exceptions to Patient Authorization
- Criminal acts: evidence used in abuse cases, stabbings, gunshot wounds, or sexual assaults
- Legally ordered: court-ordered medical records submission as evidence in a court case (subpoena)
HIPAA Requirements
- Covered entities (health insurance companies, clearinghouses, providers) must adhere to HIPAA
- Employers are not considered covered entities
- HIPAA Security Rule: implement reasonable and suitable safeguards to protect protected health information and prevent breaches of confidentiality
- HIPAA requires explanation of patient rights and written consent when sharing health care information
- Patients must sign a form indicating receipt of a privacy notice from a health care provider or hospital
HIPAA Safeguards
- Administrative safeguards: written policies and procedures for HIPAA compliance
- Physical safeguards: physical monitoring and access to protected health information (PHI)
- Technical safeguards: monitoring and safeguarding patient information through technology-related items
Patient Data Ownership
- Patients own the information within the medical record, but the health care provider owns the medical record
- Medical records are legal documents that must remain with the health care facility
Good Samaritan Acts
- Allow bystanders to get involved in emergency situations without fear of liability
Genetic Information Nondiscrimination Act of 2008 (GINA)
- Prohibits discrimination on the basis of genetic information with respect to health insurance and employment
Patient Safety and Quality Improvement Act (PSOIA)
- Framework for gathering and analyzing information regarding patient safety within protected health information laws
Anti-Kick Back Statute (AKBS)
- Criminal law that prohibits receiving benefits for referral or business involving federal health care programs
No Surprise Act (NSA)
- Protects individuals from surprise billing for emergency services from an out-of-network provider or facility without prior authorization
Good Samaritan Acts
- Allows bystanders to assist in emergency situations without fear of being sued for their actions.
Genetic Information Nondiscrimination Act (GINA)
- Prohibits discrimination based on genetic information with respect to health insurance and employment.
Patient Safety and Quality Improvement Act (PSOIA)
- Provides a framework for gathering and analyzing information regarding patient safety within protected health information laws.
Anti-Kick Back Statute (AKBS)
- Prohibits receiving benefits for referral or business involving federal health care programs.
No Surprise Act (NSA)
- Protects individuals from surprise billing for emergency services from an out-of-network provider or facility without prior authorization.
Protect Patient Privacy and Confidentiality
- Legal requirements for maintenance, storage, and disposal of records are essential to protect patient privacy.
Sharing Information and Release of Information
- The medical record contains sensitive information regarding patient history, current health status, and planned treatment.
- Patients have the right to inspect, review, and receive a copy of their medical records and billing records held by health plans and health care providers.
- Only patients and authorized representatives have the right to access the patient's medical record.
- The medical provider or facility owns the actual medical record, but the patient owns the information within the record.
Exceptions to Release of Medical Records
- Criminal acts: evidence used in abuse cases, stabbings, gunshot wounds, or sexual assaults.
- Legally ordered: court-ordered release of medical records through subpoena.
- Communicable diseases: release of information required by the Centers for Disease Control and Prevention or local health departments.
- Mandated examinations: ordered by employers' insurance companies for workers' compensation cases.
Informed and Implied Consent
- Consent is an act of reason, requiring sufficient mental capacity and possession of essential information.
- Consent must be free of force or fraud.
Types of Consent
- Implied Consent: inferred based on signs, actions, or conduct of the patient.
- Expressed Consent: given through oral or written words.
- Informed Consent: ensures the patient knows, understands, and accepts the treatment that has been explained.
Good Samaritan Acts
- Allows bystanders to assist in emergency situations without fear of being sued for their actions.
Genetic Information Nondiscrimination Act (GINA)
- Prohibits discrimination based on genetic information with respect to health insurance and employment.
Patient Safety and Quality Improvement Act (PSOIA)
- Provides a framework for gathering and analyzing information regarding patient safety within protected health information laws.
Anti-Kick Back Statute (AKBS)
- Prohibits receiving benefits for referral or business involving federal health care programs.
No Surprise Act (NSA)
- Protects individuals from surprise billing for emergency services from an out-of-network provider or facility without prior authorization.
Protect Patient Privacy and Confidentiality
- Legal requirements for maintenance, storage, and disposal of records are essential to protect patient privacy.
Sharing Information and Release of Information
- The medical record contains sensitive information regarding patient history, current health status, and planned treatment.
- Patients have the right to inspect, review, and receive a copy of their medical records and billing records held by health plans and health care providers.
- Only patients and authorized representatives have the right to access the patient's medical record.
- The medical provider or facility owns the actual medical record, but the patient owns the information within the record.
Exceptions to Release of Medical Records
- Criminal acts: evidence used in abuse cases, stabbings, gunshot wounds, or sexual assaults.
- Legally ordered: court-ordered release of medical records through subpoena.
- Communicable diseases: release of information required by the Centers for Disease Control and Prevention or local health departments.
- Mandated examinations: ordered by employers' insurance companies for workers' compensation cases.
Informed and Implied Consent
- Consent is an act of reason, requiring sufficient mental capacity and possession of essential information.
- Consent must be free of force or fraud.
Types of Consent
- Implied Consent: inferred based on signs, actions, or conduct of the patient.
- Expressed Consent: given through oral or written words.
- Informed Consent: ensures the patient knows, understands, and accepts the treatment that has been explained.
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Description
This quiz covers the laws and regulations that healthcare professionals, including medical assistants, must follow to provide high-quality patient care and protect patient privacy.