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Questions and Answers

What is the primary purpose of medical recording on computers?

To make charting more difficult

To ensure that charts are never lost

To allow for easy access to patient information (correct)

To reduce the amount of information recorded

What is the responsibility of healthcare workers when it comes to charting?

To make the charts as inconsistent as possible

To ensure that the charts are never allowed to leave the healthcare facility (correct)

To make the charts as subjective as possible

To make the charts as incomplete as possible

What is the purpose of the 'at a glance' card located at the beginning of a patient's medical chart?

To provide basic patient medical information (correct)

To list the patient's favorite food

To list the patient's favorite color

To provide information about the patient's hobbies

What is the legal retention period for diagnostic images?

5-7 years Signup and view all the answers

What is the purpose of an Incident Report or Unusual Occurrence Form?

To report patient falls or accidents Signup and view all the answers

What is the responsibility of radiologic technologists when it comes to medical recording?

To access pertinent information about the patient using the Radiology Information Management System (RIMS) Signup and view all the answers

What is the purpose of a release form when it comes to digital images of a patient?

To allow the digital images of a patient to be sent electronically to other healthcare facilities Signup and view all the answers

What is the primary purpose of charting?

To ensure that charting is clear, self-explanatory, complete, objective, consistent, and accurate Signup and view all the answers

What is the legal status of diagnostic images?

They belong to the institution in which they are made Signup and view all the answers

What is the responsibility of healthcare workers when it comes to medical recording?

To ensure that medical recording is clear, self-explanatory, complete, objective, consistent, and accurate Signup and view all the answers

What is the purpose of a Radiology Information Management System (RIMS)?

To access pertinent information about the patient Signup and view all the answers

What is the purpose of the brief 'at a glance' card located at the beginning of a patient's medical chart?

To provide basic patient medical information Signup and view all the answers

What is informed consent?

An agreement or permission accompanied by full notice/explanation about the care, treatment, or service that is the subject of the consent. Signup and view all the answers

What must the patient be apprised of before a medical procedure or treatment?

The nature, risks, and alternatives of the procedure or treatment. Signup and view all the answers

What is the most frequent root cause of serious adverse events reported to The Joint Commission’s sentinel event database?

Communication issues. Signup and view all the answers

What are some barriers to patient understanding during the informed consent process?

Lack of basic information on the consent form, ineffective provider-patient communication, lack of consideration of the health literacy and cultural issues of patients. Signup and view all the answers

What are some ways health organizations can better serve their patients during the informed consent process?

Promoting informed consent as a process of effective communication between provider and patient, having clear written policy on informed consent for care, providing a formal training program to physicians, simplifying the content, length, and language of informed consent documents, and providing communication models for physicians to evaluate patient understanding. Signup and view all the answers

What are some patient rights?

Considerate and respectful care, information, privacy and confidentiality, and the right to ask to see and get a copy of your health records, have corrections added to your health information, receive a notice that tells you how your health information may be used and shared, and decide if you want to give your permission before your health information can be used or shared for certain purposes. Signup and view all the answers

What are the seven elements of the informed consent process?

Discussing the patient's role in the decision-making process, describing the clinical issue and suggested treatment, discussing alternatives to the suggested treatment, discussing risks and benefits of the suggested treatment, discussing related uncertainties, assessing the patient's understanding of the information provided, and eliciting the patient's preference. Signup and view all the answers

Can patients refuse treatment or examination after informed consent is signed?

Yes. Signup and view all the answers

Under what conditions do terminally ill patients have the legal right to request aid in dying?

Under certain conditions. Signup and view all the answers

Who legally owns diagnostic images?

The institution in which they are made, not the patient. Signup and view all the answers

What must be done if a patient, visitor, or staff member has an accident or fall that results in injury or potential harm?

It must be reported immediately to the department supervisor or radiologist or both by completing an Incident Report or Unusual Occurrence Form. Signup and view all the answers

Study Notes

Informed Consent and Patient Rights: Key Points to Consider

Informed consent is the agreement or permission accompanied by full notice/explanation about the care, treatment, or service that is the subject of the consent.
The patient must be apprised of the nature, risks, and alternatives of a medical procedure or treatment before the physician or other health care professional begins any such course.
Challenges to implementing an effective informed consent process include patients frequently not understanding the risks, benefits, and alternatives involved in their course of treatment or surgical procedure.
Informed consent is a process of communication between a clinician and a patient that results in the patient’s authorization or agreement to undergo a specific medical intervention.
Communication issues are the most frequent root cause of serious adverse events reported to The Joint Commission’s sentinel event database.
Barriers to patient understanding and communication challenges include a lack of basic information on the consent form, ineffective provider-patient communication, lack of consideration of the health literacy and cultural issues of patients.
Ways health organizations can better serve their patients during informed consent include promoting informed consent as a process of effective communication between provider and patient, having clear written policy on informed consent for care, providing a formal training program to physicians, simplifying the content, length, and language of informed consent documents, and providing communication models for physicians to evaluate patient understanding.
Patient rights include considerate and respectful care, information, privacy and confidentiality, and the right to ask to see and get a copy of your health records, have corrections added to your health information, receive a notice that tells you how your health information may be used and shared, and decide if you want to give your permission before your health information can be used or shared for certain purposes.
The informed consent process consists of seven elements, including discussing the patient's role in the decision-making process, describing the clinical issue and suggested treatment, discussing alternatives to the suggested treatment, discussing risks and benefits of the suggested treatment, discussing related uncertainties, assessing the patient's understanding of the information provided, and eliciting the patient's preference.
Patients have the right to refuse treatment or examination, even after informed consent is signed.
Terminally ill patients have the legal right to request aid in dying under certain conditions, and a Do Not Resuscitate (DNR) order and/or a Do Not Intubate (DNI) order indicated the patient’s choice that neither resuscitation nor intubation is to be undertaken.
Patient medical records can be in paper format, electronic format (e-charts), or both, and diagnostic images are legally considered to be part of the medical record and belong to the institution in which they are made, not to the patient.
Any patient’s or visitor’s or staff’s fall, accident, or occurrence that results in injury or potential harm must be reported immediately to the department supervisor or radiologist or both by completing an Incident Report or Unusual Occurrence Form.

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Description

Test your knowledge on informed consent with this informative quiz! Learn about the key principles and requirements involved in obtaining informed consent from patients before medical procedures or treatments. This quiz will cover topics such as the nature, risks, and alternatives of medical procedures, as well as the legal and ethical considerations involved. Sharpen your understanding of informed consent by taking this interactive quiz today!