1. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Agenda: Seminar 6 Discussion of Unit 4 Project Chapter 9 Material Remember to take the Unit 6 Quiz! If you complete it quickly, use your extra time to check your answers!

2. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Unit 4 Project Overall, answers need to be longer. A one-sentence answer is probably not going to answer the question completely. The exception is where the question simply asks for a list of items (like question 2 from the unit 4 project). RESEARCH! Many of the answers can be found in the book. You may consult the index in the back of the book to help find the answer. Spelling/Grammar: Use your spell-checker and read it before submitting it to check for grammar issues. Seek help from the Kaplan Writing Center. Make sure your answer addresses the question asked.

3. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Examples of Project Answers Question: What is the difference between civil law and criminal law? Answer 1: Civil law is generally for the civilians and criminal law is for the criminals. It would be agains the law for civilians to commit crimes. That is why they are called cibil and criminal laws. Answer 2: There are many differences between civil and criminal law, including parties involved, purposes, and standards of proof. Civil law generally concerns disputes between two private parties. (Fremgen, pg. 32) The purpose of civil law is to make a damaged party whole by award of money damages, injunctions, or other court-ordered relief. (Fremgen, pg. 32) There are many types of civil actions, such as class action lawsuits, contracts, and torts. (Fremgen, pg. 32-38) In contrast, criminal law serves a very different purpose. Criminal laws protect the public by punishing socially intolerable acts. (Fremgen, pg. 38) In a criminal case, the government prosecutes accused criminals, resulting in fines, imprisonment, or both if the accused is found guilty. (Fremgen, pg. 38-39) Since accused criminal cases are deprived of liberty if found guilty, the defendant must be proven guilty beyond a reasonable doubt, whereas a defendant must be proven liable by a preponderance of the evidence standard in a civil case. (Fremgen, pg. 44)

4. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Medical Law and Ethics The Medical Record Chapter 9

5. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. The Medical Record All written documentation relating to patient Includes – Past history – Current diagnosis and treatment – Correspondence relating to patient Is a legal document May be subpoenaed

6. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. What is the purpose of the medical record?

7. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Purpose of the Medical Record Record of patient from birth to death Document for continual management of patient’s health care Provides data and statistics Tracks ongoing patterns of patient’s health

8. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Contents of the Medical Record Personal information about patient Clinical data or information – Records of medical examinations – X-rays – Lab reports – Consent forms – Referrals: PT/OT – Prescriptions and refills

9. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 9.2 Example of SOAP Charting

10. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Two Common Forms of Charting POMR: Problem-Oriented Medical Record includes chronological record of each visit SOAP: subjective, objective, assessment, plan – Subjective statements of patient – Objective data such as lab reports, vital signs – Assessment or diagnosis – Plan of treatment

11. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. What action should be taken if you identify an error in a patient’s medical record?

12. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Corrections and Alterations Draw one line through error Write correction above error Date and initial change Do not erase or use correction fluid Falsification of medical record is grounds for criminal indictment

13. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 9.3 Example of Corrected Chart Notation

14. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Timeliness of Documentation Medical records must be accurate and timely All entries must be made as care occurs or as soon as possible afterward Should be completed by physician within 30 days following patient's discharge from hospital

15. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Completeness of Entries Medical records document type and amount of patient care that was given In eyes of court, “if it’s not documented, it wasn’t done”

16. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Confidentiality Medical records should not be released to a third party without patient’s written consent Only specific records requested should be copied and sent Taking photos or other visual images of patient without consent is invasion of patient’s privacy

17. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ownership Physicians or owners of health care facility own the medical record Patients have legal right of “privileged communication” and access to records

18. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ownership (continued) Patients must authorize release of records in writing Doctrine of professional discretion: physician may determine, based on his or her best judgment, if patient with mental or emotional problems should view medical record

19. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Release of Information Never send entire medical chart unless it is requested Do not send original

20. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Release of Information (continued) Record may not be released to patient without physician’s permission Patient must sign release form for information to be sent to insurance company

21. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Privacy Act of 1974 Agency may maintain only information relevant to its authorized purpose Citizens have right to gain access to records and to copy records if necessary Applies only to federal agencies and government contractors

22. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. State Open Record Laws Some states have freedom of information laws that grant public access to records maintained by state agencies Medical records generally are exempt from this statute

23. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Alcohol and Drug Abuse Patient Records Public Health Services Act protects patients who are receiving treatment for drug and alcohol abuse Person or program that releases confidential information relating to these patients is subject to criminal fines Exception if patient should require emergency care

24. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Retention and Storage of Medical Records Each state varies on length of time records must be kept Legally, records must be stored for a minimum of ten years from time of last entry Minor’s records must be kept until patient reaches age of maturity plus period of the statute of limitations

25. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Storage Current records usually kept within physician's office May rent storage space May be placed on microfilm Kept in fire-proof, locked area

26. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Computerized Medical Records Data on patient records can be created, modified, authenticated, stored, and retrieved by computer Special safety measures should be taken to establish personal identification and user verification codes for access to records Should be accessed on need-to-know basis

27. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Reporting and Disclosure Requirements State laws require disclosure of some confidential medical record information without patient’s consent Reporting and disclosure are duties of the physician

28. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Use of Medical Record in Court Improper Disclosure: health care providers and institutions may face civil and criminal liability for releasing medical records without proper patient authorization Subpoena Duces Tecum: written order requiring person to appear in court, give testimony, and bring information described in subpoena

29. Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. What steps should be taken to ensure that the medical record is maintained as a legal document? Give an example of when legal regulations and ethical standards come into conflict with respect to medical records.