110 Legal Concepts part 2.pptx

Legal Concepts Focus on the differences and how each term applies  Regulation Statutes Standards Policy Procedures s A law The A deliberate Establis...

Legal Concepts Focus on the differences and how each term applies  Regulation Statutes Standards Policy Procedures s A law The A deliberate Established or Laws that system of official way of established expected are enforced guidelines to guide doing a task, or by a conduct of a decisions and by state and series of tasks legislative professional achieve rational federal outcomes. A policy that promote body. Think in any given uniformity, agencies is a statement of state law, circumstanc intent and is often based on county law, e implemented as a experience federal law. procedure or protocol. Allegatio Affidavi n: t: Complaint: Voluntary statement of A claim that someone facts sworn to be true has done something before an authority. wrong or illegal The first pleading filed by the plaintiff’s attorney Subpoena: Legal order/court order to appear and testify or to produce requested documentation Any participating party: Plaintiff, defendant or Deposition: witnesses may be asked to participate in this pretrial discovery. They are asked questions under oath, not in front of a jury. Indictment: This is the formal writing accusation from the grand jury. In other words, this means they have decided that the defendant should be put on trial. Precedent: A legal principle created by a previous court decision that provides an example for how to decide in similar cases. Torts: This is a civil wrong, It may be intentional or unintentional. Just because the harm is unintended does not mean that the plaintiff is not guilty.  Types of Torts: Intentional Tort Assault: act that causes another fear that he/she will be touched in an offensive, insulting manner without consent to do so. Battery: physical act of harmful or unwarranted contact with a person without proper consent. Defamation: slander (oral statement) or Libel: :Slander libel (written statement) that damages a person's reputation. False Imprisonment: illegal detention of a person without consent. Intentional Infliction of Emotional Distress: disparaging remarks made about a patient that resulted in emotional distress. Invasion of Privacy: disclosure of private information concerning a patient or photographing a patient without his/her Types of Torts: Unintentional Tort Patient Misidentification Performing Incorrect Procedure Retained Foreign Bodies: Patient Burns Falls or Positioning Errors Improper Handling/Lost Specimens Incorrect Drug or Administration Loss or Damage of Patients Property Harm from Major Break in Sterile Technique Harm from Use of Defective Equipment Violation of Hospital Policy Patient Abandonment How to avoid torts: Stay within scope of practice Follow hospital policy and procedure Get consent from the patient Work with a questioning attitude Understanding safety events and commit to making them personal work habits  Documentation In the healthcare field documentation refers to inputting information into the patients medical record or chart. Patients medical records can include a variety components through many different departments or providers: Patient Identification Insurance Coverage History & Physical (H&P) Diagnosis Diagnostic Procedures (e.g. imaging studies) Medication Record Intraoperative Record Preoperative Record Anesthesia Record Discharge and/or Information s documentation different in the OR? Examples of items documented within the Intraoperative Record: Staff present in the room during the procedure (in and out times). Patients condition prior, during, and after surgery. Patient positioning and placement of padding or monitoring devices. Patient skin prep (what, how, where, who) Insertion of urinary catheter (Who, type, when) Surgical Counts : who, when, layers, items included Initiation (incision) and Termination (closure) times of procedure. Drains and Dressing applications Specimens Implants (S/N, type, size, brand, quantity, location) Procedure specific charges (insurance purposes)