Medical Law and Ethics Lesson 3: Documentation and Regulations

Lesson Objectives Upon completion of this lesson, students should be able to … Discuss the role of the medical assistant relating to legal issues in the medical office.

Documentation It is critical to carefully document what happens in the medical office. If an action is not recorded on the medical chart, then it is considered by the court not to have been performed.

Information Documented in a Patient’s Chart Calls and visits Treatments No-shows Appointment cancellations Medications Prescription refills Vital signs Other pertinent information

Cautions with Documentation Be careful with fax transmissions of medical records Receiving fax must be located in a restricted area A disclaimer should be placed on the fax cover explaining that records are confidential

Court Testimony If you are asked to testify in court… ◦ Be professional ◦ Remain calm, dignified, and serious ◦ Always tell the truth ◦ Do not answer questions you do not understand ◦ Just present the facts about the case

Reports Physicians Must Provide Births Stillbirths Deaths Communicable illnesses or diseases Drug abuse Certain injuries Abuse of child and adults Gunshot and knife wounds Animal bites

Mandated Reporter Must report abuse or risk fines and/or jail time

Child Abuse Physicians have a duty to report questionable injuries of children Requirements differ by state These injuries include: ◦ Bruises ◦ Fractured bones ◦ Burns ◦ Malnutrition ◦ Poor growth ◦ Lack of hygiene

Critical Thinking Question Why is the reporting of child abuse necessary and required?

Elder Abuse Physicians have a duty to report questionable injuries of the elderly These requirements include: ◦ Physical abuse ◦ Neglect ◦ Abandonment Requirements differ by state

Critical Thinking Question 1. Why is this reporting of elder abuse necessary and required?

Drug Abuse Abuse of prescription drugs must be reported Patient may go to several different doctors for the same drug A physician should always see the patient before prescribing drugs

Form DEA 224 Used by physicians to register with the DEA Allows physicians to prescribe, dispense, or administer controlled substances Renewal is required every 3 years

Requirements for Controlled Substances Controlled drugs must be kept in a double-locked cabinet Any theft must be immediately reported Physician’s black bag and prescription blanks should always be stored in a secure, locked location

Schedule for Controlled Substances Schedule I (cocaine, LSD) ◦ Highest potential for addiction and abuse Schedule II (Morphine) ◦ High potential for addiction and abuse Schedule III (anabolic steroids) ◦ Moderate to low potential for addiction and abuse Schedule IV (valium) ◦ Lower potential than Schedule III drugs Schedule V (tylenol w/codeine) ◦ Low potential for addiction and abuse

Role of the Medical Assistant Does not dispense controlled substances Must be knowledgeable about the regulations of the drugs Only licensed personnel are permitted to dispense drugs Always report any unusual patient behavior indicating addictive drug use

Ways to Help Your Employer Follow the chain of command Report to your immediate supervisor If you make an error, bring it to your supervisor’s attention immediately

If you are aware of illegal activity and remain silent, you may be liable. MA’s Role Related to Confidentiality/Privacy Issues Never make any statements that could be interpreted as an admission of fault Do not remain silent if you are aware of illegal activity Do not participate in negative discussions of the physician with patients

MA’s Role Related to Confidentiality/Privacy Issues Never discuss anything about the patient outside of the office Make sure that a female MA is present when the physician (male or female) examines a female patient Treat all patients with dignity and respect

MA’s Role Related to Office Management Treat all patients with courtesy and dignity Log and return telephone calls promptly Explain any delays to patients Offer to set up another appointment if the delay will be very long

MA’s Role Related to Office Management Never make promises regarding what the physician can do Carefully explain all fees and responsibilities for bills Relay any concerns about bills from the patient to the physician Relay patient comments to the physician

Medical documents are legal documents and may be used in a court of law. MA’s Role Related to Documentation Carefully sign or initial every note document the no-show’s Document referrals to another physician Follow up to make sure the patient did see the referral physician

MA’s Role Related to Documentation Document all patient contacts, including telephone prescription refills and tests and procedures that have been ordered Call all patients the day after surgery to check on their progress and document this call

MA’s Role Related to Documentation Record all care and treatment given as soon as possible Be sure the physician sees and initials all diagnostic reports before they are filed Provide all patient instructions in writing

MA’s Role Related to Drug Regulations May administer medication only under the direct supervision of a physician Follow the Controlled Substances Act Know state laws Secure the supply of prescription pads from theft at all times

MA’s Role Related to Drug Regulations When preparing medications for administration, check the medication three times: ◦ Before removing it from the shelf ◦ Again, before preparing the dosage ◦ Before returning the medication to the shelf

Continue your education and training to maintain your skill levels. MA’s Role Related to Certification and Licensing Know the limits of certification and standards of care Never perform any procedures for which you are not trained or qualified Do not diagnose or prescribe drugs over the telephone (even OTC drugs) Do not call yourself a “nurse” or allow anyone else to refer to you as one

File signed informed consents immediately! MA’s Role Related to Informed Consent Physician must explain all procedures to the patient MA is responsible for making sure there is a signed consent form Never have a patient sign a document that he or she does not understand Obtain a parent/guardian’s signature before providing care to a minor except in the case of an emergency

If you knowingly overlook a hazard you could be found guilty of negligence! MA’s Role Related to Safety Issues Maintain a safe environment Report any safety hazards at once

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