Presentation on theme: "Law, Documentation & Ethics"— Presentation transcript:
1Law, Documentation & Ethics RTEC 93Veinpuncture and Pharmacology for Radiologic Technologists
2ASRTIncludes venipuncture and IV medication administration in the curriculum guidelines for the educational opportunities offered to technologists.Standards of Practice for Radiography
3American College of Radiology (ACR) Additional support for the administration of medications and venipuncture as part of the technologist’s scope of practice if found in the 1987 Resolution No. 27
4Veinpuncture LawsCALIFORNIA HEALTH AND SAFETY CODEHEALTH AND SAFETY CODE SECTION
5Hospital Policies for Radiologic Technologists Competency in venipuncture and IV contrast administration requires the completion of a formal course of instruction and supervised clinical practice and evaluation
6Standard of CareDegree of skill (proficiency), knowledge, and care ordinarily possessed & employed by members in good standing within a profession.To test whether the standard of care has been met, one must determine what a reasonable, prudent practitioner would have done under similar circumstances.
7Causes of Legal ActionApprox 10% of all medical negligence claims are somehow related to diagnostic imaging.Medical Negligence – failure to use such care as a reasonably prudent health care professional would use in similar circumstances.
8Four Elements to Prove Negligence Must establish a duty to the patient by the health care providerBreach of this duty by an act or by failing to perform some act.A compensable injuryA causal relation between the injury and the breach of duty.
9Cause of Legal ActionTort – Civil wrong committed by one individual against another. May be classified as either intentional or unintentional. This type of claim arises from a breach of duty. ex: less than optimal care, threatened, or injured in departmentUsually based upon legitimate concerns of negligent care or claims of assault, battery, or false imprisonment.
10Cause of Legal ActionAssault – Any willful attempt or threat to inflict injury on the person and any intentional display of force that would give the victim reason to fear or expect immediate bodily harm.Battery – An unlawful touching of another that is without justification or excuse. Ex: a technologist performs an exam or touches a patient without that patient’s permission, even if no injury arises from such contact.
11Cause of Legal ActionFalse Imprisonment – Conscious restraint of another without proper authorization, privilege, or consent. The more common claim of false imprisonment arises when a person is restrained against his or her will.Defamation – Holding up a person to ridicule, scorn, or contempt in a respectable & considerable partof the community.
12Corporate LiabilityRequires the hospital or health care entity to be responsible for the quality of care delivered to consumers.Health care corp. must assess & evaluate the quality of care delivered & must be prepared to make changes as needed.The corp. may be required to intervene if suboptimal care is being provided by one of its independent contractors.
13Informed ConsentA person’s agreement to allow something to happen (i.e surgery) that is based on full disclosure of the facts: knowledge of benefits, risks, and alternatives to the procedure.Required when a patient is subjected to any type of invasive procedure.If the pt consents to a procedure & then revokes the consent, the doctor must stop the procedure.
14The LawEvery human being of adult years and sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages.
15Six functions of this Law Protects individual autonomyProtects the patient’s status as a human beingAvoids fraud and duressEncourages health care practitioners to carefully consider their decisionsFosters rational decision making by the patient, andInvolves the public in medicine
16The Health Record in Court The radiograph as evidenceDark/light radiographMis-marked filmsWrong patient information
17DocumentationIn court, if you testify that you properly assessed the patients medical risk and obtained consent from the patient verbally prior to the examination; will that serve as meeting the Technologist Standard of Practice?
18DocumentationFederal requirements and the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) require that the medical staff of an institution have bylaws, rules and regulations that include a provision for accurate and complete medical records with the original copies of documents in the patient record.
19The record is a means of communication between the healthcare professionals who are treating the patient.
20Must Include: Patient identification date Medical history of the patient, including chief complaint; present illness or injury; relevant past, family and social histories; and inventory by body systemsReport of relevant physical examinationDiagnostic and therapeutic ordersClinical observations, including results of therapy
21Reports of diagnostic and therapeutic procedures and test as well as their results Evidence of appropriate informed consent (when consent is not obtainable, the reason should be entered in the record)Conclusions at termination of hospitalization or evaluation of treatment, including any pertinent instructions for follow-up care
22Charting Drug Information Any time a drug is administered to an inpatient it must be chartedInformation includes:Drug nameDose of the drugRoute of administration (if parenterally, then the side of injection)Date & Time
23DocumentationThe five rights of medication administration is to be included in every patient’s permanent medical record.The size, type and location of the needle, number of venipuncture attempts; and the identity of the health care personnel who performed the procedure.
24Document Meds Given 5 rights of medication administration: The right patientThe right medicationThe right routeThe right amountThe right time
25Exampleat 0900 a venous access of Mr. Jones was performed using an 20-gauge antiocatheter. The access was established in the antecubital of the left arm after one attempt. Then 100 ml of Isovue 300 was administered by IV push via the access. The patient tolerated the injection procedure and medication without complaints of pain and with no unexpected side affects. K. Clark, R.T.
26Charting Exam Completion M.D.’s order in patient’s chart should be verified prior to examinationDocument exam completion next to M.D.’s written orderEx: 4/25/07, 1300, 2 view CXR complete K. Clark (RT)
27HIPPAThe Health Insurance Portability and Accountability Act of 1996 mandates that federal laws or regulations ensure the confidentiality of medical records.Patients or representatives should have access to all records except in the event the provider feels that it is not in the best interest of the patient’s health to have access or if the knowledge of the health care information could cause danger to the life or safety of any person.
28HIPPA Within radiology: Technologists are sometimes asked by patients if they can examine their records while in transit, waiting for a procedure or undergoing an examination. The record information should not be shared with the patient in this fashion as this may lead to misinterpretation of information.
29Documentation As applied to radiology: Assess the order: procedure requested, identifying information, doctorThe report: results are kept in patient chart
31The Importance of a Professional Ethic Ethics: the systematic study of rightness and wrongness of human conduct and character as know by natural reasonProfessional Ethic: the ethical conduct of a profession
32Ethical DilemmasA situation requiring moral judgment between two or more alternatives; there are two or more competing moral norms present, creating a challenge about what to do
33Ethical Analysis 1. identifying the problem 2. developing alternative solutions3. selecting the best solution4. defending your selection
34Professional EthicConduct must support the emotional and physical needs of the patientPatient privacy and dignity or even the simple right to be told the truth must be adhered toAssist in providing accurate information which enables physicians to make proper diagnosis
35REMEMBERRadiology Technologist are legally liable for their actions in the daily performance of diagnostic procedures.Health care practitioners who do not remain current in the field or who do not follow the accepted standard may be liable under the legal theory of medical negligence.
36Identifying the Problem Thoroughness in problem identification, looking at every possible twist or nuance in a given situation
37Developing Alternative Solution Attempt to exhaust all possible pathways to a resolution of the dilemma, taking care to view the dilemma from the perspective not only of the patient and the patient’s family but also the health care professionals and administrators to whom they entrust their care.
38Selecting the Best Solution Most challenging stepIt is a personal activity that involves choosing an alternative not only based on widely held moral stands but one that is also in full accord with your own individual value system
39Defending Your Selection Explain the basis for your ethical decision in terms that you can justify to colleagues and patients alike
40Situation Judgment Tests – SJT’s “I Think Dr. Jones Misread the Film” You have just finished a routine radiologic procedure on Mrs. Green. As you develop the film, it becomes clear that Mrs. Green is probably suffering from a rare form of bone disease. Dr. Jones, a young resident, glances at the film and smiles. “I didn’t think Mrs. Green had anything to worry about,” he says. “That joint pain she was complaining about must be all in her head.” Later, you see Dr. Jones talking to Mrs. Green’s family. He is smiling and joking with them as he signs Mrs. Green’s discharge papers. Shaken, you mutter to yourself, “I think Dr. Jones misread the film.” What should you do”