AMCA Clinical Medical Assistant Study Guide for Medical Law and Ethics

**[AMCA Clinical Medical Assistant Study Guide for Medical Law and Ethics]** The Clinical Medical Assistant should have knowledge of the following to be able to properly collect specimens: - Knowledge of the anatomy and physiology of the integumentary, cardiovascular, musculoskeletal, and ne...

**[AMCA Clinical Medical Assistant Study Guide for Medical Law and Ethics]** The Clinical Medical Assistant should have knowledge of the following to be able to properly collect specimens: - Knowledge of the anatomy and physiology of the integumentary, cardiovascular, musculoskeletal, and nervous systems. - Knowledge of phlebotomy equipment and supplies. - Knowledge and skills for performing phlebotomy. - Ability to communicate and be understood by patients. - Knowledge of legal aspects of performing an invasive procedure. The phlebotomist's role in transporting specimens includes: - Having the correct specimen and lab req/order (if needed). - Verifying the patient labels and the lab requisition are for the same patient. - Verifying the orders and information on the lab requisition. - Understand the requirements for each specimen's transportation needs. - Transporting the specimen(s) according to facility procedures and policies. - If transporting the specimen on roadways, following the Department of Transportation's laws. Congress passed the CLIA (Clinical Laboratory Improvement Amendments) which established standards for improving the quality of laboratory testing in the United States. CLIA consists of federal regulations governing all facilities that perform laboratory testing. CLIA regulations established the following three categories of laboratory testing based on the complexity of the testing methods: - **Waived Tests** o A laboratory test that has been determined by HHS to meet the CLIA criteria for being a simple procedure and has low risk for erroneous test results. Waived tests include tests that have been approved by the Food and Drug - **Moderate-Complexity Tests** o A Moderate-complexity test is a nonwaived test that is subject to the CLIA 1998 regulations. Most of these tests are performed at hospitals and independent laboratories, and some medical offices. Some examples of Moderate-Complexity tests are urine and throat cultures, hematology, and blood chemistry tests. - **High-Complexity Tests** o High complexity tests are non-waived tests that are subject to the CLIA 1998 regulations. These tests are not completed in medical offices and are performed in laboratories already subject to federal regulations. Some examples of high complexity tests are cytogenetics, histopathology, and cytology tests. A medical assistant does not perform these tests. The Centers for Medicare and Medicaid Services (CMS) ==================================================== CMS is a division of the Department of Health and Human Services. The CMS is responsible for regulating and operating under the CLIA program. In addition to the following CLIA regulations, a clinical laboratory must comply with all other federal, state, and local laboratory regulations. One of the steps in phlebotomy includes correct identification of the patient in a two-step process. Asking for the patient's full name and date of birth is the most common way to validate the patient's identification as mandated by The Joint Commission. Phlebotomy is an invasive procedure that must follow approved and accredited procedures to protect both the patient and the facility. Verifying the patient's identification BEFORE the procedure and verifying that the labels on the specimens are the patient's labels/information AFTER the procedure is a 2-step process that protects the patient and the facility. The patient also has the right to refuse to be drawn. When this happens, the phlebotomist MUST document this refusal in the patient's EMR or paper chart as the EMR and/or paper chart are legal documents. These documents may be used if legal proceedings ensue. Patient Rights ============== Patient's rights may be legally defined by the state or an institution. The Patient's Bill of Rights is referred to as the Consumer Bill of Rights and Responsibilities, which was adopted by the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry. This document was created to improve consumer trust in the Health Care System by defining the rights and responsibilities of consumers, health care professionals, health care institutions, and insurance plans. The Patient's Bill of Right's varies from state to state. The Medical Assistant and all employees of the medical field must protect the patients' rights. Patients actively participate in their own health care. The Patient Care Partnership serves as a guide for both patients and their physicians involved in their care. Patient Care Partnership ======================== As a patient in XXX Hospital, you have the right, consistent with law, to: - Receive treatment without discrimination as to race, color, religion, gender, national origin, disability, or the source of payment. - Be informed of the name and position of the doctor who will oversee your care in the hospital. - Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment. - Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask. - Refuse treatment, examination, or observation, if retired or a family member, and be told what effect this may have on your health. - Privacy while in the hospital and confidentiality of all information and records regarding your care. - Review your medical record without charge. Obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay. - Complain without fears of reprisals about the care and services you are receiving and to have the hospital respond to you; and if requested, a written response. If you are not satisfied with the hospital\'s response, you can complain to the Patient Representative Office located here in the hospital. - Receive information about pain and pain relief measures, be involved in pain management plans, and receive a quick response to reports of pain. - The right to request information about advance directives regarding your decisions about medical care. - Make known your wishes regarding anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the hospital. A patient may also have a document that expresses his or her wishes in case of terminal illness or an accident after which they cannot express their wishes. This document is called a Living Will. Safety measures are an important component of the laboratory. Laboratory testing involves the collection and handling of specimens that may contain pathogens. In addition, laboratory testing includes the use of hazardous chemical reagents. It is important that safety measures for equipment, supplies, and the emergency devices be available and readily accessible in the laboratory. It is the responsibility of the Medical Assistant to know where to find the laboratory's policies and procedures for maintaining the safety of the Laboratory. It is imperative that the Medical Assistant complies with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard and review the Safety Data Sheet (SDS)for the chemical reagent before using it. Preventing Infection ==================== Infection is a major threat and health hazard in all our health care facilities. Everyone is at risk and prevention of that risk is an important part of everyone's job description. The primary goal of an infection control program is to prevent the spread of infection in a health care facility. - AIDS - AIDS stands for acquired immunodeficiency syndrome and is caused by a virus called human immunodeficiency virus. Most exposures to HIV in healthcare settings are the result of accidental needle sticks. AIDS is transmitted by blood, vaginal fluids, and semen and is not spread through casual contact. AIDS also may be transmitted through the blood of an infected person that enters another person's bloodstream through a cut, an open sore, or blood that is splashed into the mouth or the eye. Thus, appropriate personal protective equipment must be worn when one is encountering body fluids from all patients. - Hepatitis B - This disease is caused by an inflammation of the liver that is caused by the hepatitis b virus, also known as HBV. Since health care providers are at risk for exposure, it is essential for standard blood and body fluid precautions to be practiced. The Occupational and Safety Health Administration states that employers must provide the hepatitis B vaccine for all employees who have an occupational employer risk. - Tuberculosis - This disease is caused by Mycobacterium tuberculosis, an airborne pathogen. Health care workers that encounter patients who have tuberculosis must wear personal protective equipment, such as special fitted masks. - Nosocomial infections - Any infection that first occurs during a patient's stay at a health-care facility, regardless of whether it is detected during the stay or after, is known as a nosocomial infection. These infections are usually transmitted to the patient by a health care worker. Proper hand washing techniques are the best method of preventing the spread of nosocomial infection. Learning how to put on and remove protective clothing is vital to ensure the health and wellness of the person wearing the PPE. PPE 's or personal protective equipment include: - Masks - Goggles - Face Shields - Respirator Standard Precautions ==================== Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. These measures are to be used when providing care to all individuals, whether they appear infectious or symptomatic. The standard precautions are: - Consider every person (patient or staff) as potentially infectious and susceptible to infection. - Wash hands---the most important procedure for preventing cross-contamination (person to person or contaminated object to person). o Wear gloves (both hands) before touching anything wet---broken skin, mucous membranes, blood or other body fluids, or soiled instruments and contaminated waste materials---or before performing invasive procedures. Transmission-Based Precautions ============================== The second tier of precautions is to be used when the patient is known or suspected of being infected with contagious disease. They are to be used in addition to standard precautions. In all situations, whether used alone or in combination, using the utmost care regarding patient and employee is crucial. Transmission based precautions are contact precautions, airborne precautions, and droplet precautions. Contact Precautions =================== Infectious agents (bacteria, viruses, or parasites) transmitted directly or indirectly from one infected or colonized person to a susceptible host (patient), often on the contaminated hands of a health worker. The following precautions should be taken: Wear clean, non-sterile examination gloves when entering the room. Change gloves after contact with infective material (e.g., fecal materials or wound drainage). Remove gloves before leaving the patient\'s room. Wash hands with antibacterial agent or use alcohol-based hand-rub after removing gloves. Do not touch potentially contaminated surfaces or items before leaving the room. Infection transmission can occur from touching contaminated clothing or linens -- considered direct contact. Airborne Precautions ==================== These precautions are designed to reduce the nosocomial transmission of particles 0.001mm or less in size that can remain in the air for several hours and be widely dispersed. Special air handling and ventilation are required to prevent airborne transmission. Droplet Precautions =================== These precautions reduce the risks for nosocomial transmission of pathogens spread wholly or partly by droplets larger than 0.001 mm in size. Pathogens are microbes that can cause disease. Droplet precautions are simpler than airborne precautions because the particles only remain in the air for a short time and travel only a few feet; therefore, contact with the source must be close for a susceptible host to become infected. It is recommended to wear a mask when interacting with patients to reduce the incidence of infection. The Hazard Communication Standard (HCS) is a requirement by OSHA to ensure that all employees are informed of the hazards associated with chemicals in their workplace. Employers are required to develop a hazard communication program. The HCS is a written plan that describes what the facility is doing to meet the requirements of the HCS program. The information must be made available and communicated to all employees who work with hazardous chemicals. **The Employer must comply with the following**: - Inventory of Hazardous Chemicals - Labeling of Hazardous Chemicals - Container Label Requirements - Safety Data Sheets - Employee information and training Do not Offer Medical Advice =========================== Sterilize With Care =================== Disposing of Waste ================== - - - - Take Accurate Info ================== Follow All Procedures ===================== Confidentiality of patient information is a vital ethical principle that needs to be observed by a medical assistant. Information obtained in the care of a patient must be obtained in the care of the patient and may not be revealed without the permission of the patient unless required by law. Whatever you say to, hear from, or do for a patient is confidential. HIPAA Security Rules ==================== HIPAA requires the usage of password protection on all electronic devices used to access patient information. If you work in a reception area that is visible to patients, it is important that your computer is positioned in a manner that does not reveal information to patients that may be standing close to your desk. Any information given by a patient to medical personnel that cannot be disclosed is known as privileged communication. HIPAA has allowed patients to have more control over their medical records, patients can make better- educated choices and most importantly the boundaries on patient information are strict and concise. Acknowledging the Notice of Privacy Practices is also kept on file assuring that the patient has read and understands how the provider will keep the patient's information private. people. - Tort is a wrong committed against a person or the person's property. Torts may be intentional or unintentional. - Negligence is an unintentional wrong. - Malpractice is negligence by a professional person (unintentional) Intentional torts are acts that are meant to be harmful. - Defamation is injuring a person's name and reputation by making false statements to a third person - Libel means making false statements in print, writing or through pictures - Slander is making false statements orally - Invasion of privacy is violating a person's right not to have his or her private affairs exposed - Fraud is saying or doing something to trick, fool or deceive a person. - Assault is intentionally attempting to touch or threaten a person's body without their consent - Battery is touching a person's body without their consent. - Informed Consent is when the person clearly understands what is going to be done. - Abandonment is when a provider withdraws from the care of a patient without reasonable notice of discharge - Two types of civil actions -- lack of informed consent and violation of standard of care Patient Preparation and Encounters ================================== As a medical assistant you may be responsible for various duties in the office including triage of patients, consent forms, preparing third party information, taking the patient's vital signs, and updating medical charts. - **Implied Consent** o agreement implied by the patient for examination and treatment when presenting for a routine visit; also, in an emergency consent that is assumed the patient would give if the patient could do so. - **Informed Consent** o consent that is given by the patient after all potential treatment and outcomes have been discussed for a specific medical condition, including risks and possible negative outcomes. - **Triage** o sorting and setting priorities for treatment for patients who are on the phone or at the reception desk. - **Sign** o that which can be seen, heard, measured, or felt by the examiner. Symptom ========= Legal medical types of consent: 1. Implied consent -- when a patient makes an appointment for a visit 2. Expressed consent -- verbal/spoken approval by the patient 3. Informed consent -- involves the patient's right to receive and understand all information relative to a/any specific procedure the patient will undergo at the hands of a licensed practitioner. This includes, a. Risks involved b. Why the procedure is necessary c. Proposed treatment applications d. Alternative modes of treatment and the risks involved e. Risk to patient if treatment is refused Advanced directives are legal documents which indicate the patient's choice for medical care and treatment in the event the patient is unable to make those decisions. An advanced directive is completed when a patient is alert, fully aware of his/her wishes. The advanced directive will provide instructions should the patient not be able to voice their choice in treatment. An advanced directive provides specific medical treatments to be followed, such as a breathing tube, feeding tubes, medications, and other medical treatments and care.