Professional Documents
Culture Documents
Introduction to Allied
Health Careers
Medical Law and Ethics
Medical Records
Welcome
Review of Digital Session
Q&A
Medical Ethics
Medical Ethics
Refers to the moral conduct of
people in medical professions
The members of the profession set
principles and standards for
themselves
They willingly choose to follow
through on these behaviors
Hippocratic Oath
Earliest code of ethics to govern
conduct in medicine
Statement of principles written in 400
BC by a Green physician, Hippocrates
Recited at medical school graduation
ceremonies
Notes the importance of the physician
to teach others and the obligation to
act in such a way as to never
knowingly harm a patient or divulge a
confidence
C.
D.
E.
Class Activity
AMA Code of Ethics
Medications
Physician orders
Radiology reports
Laboratory reports
Operative reports
Consultation
reports
ECGs
Miscellaneous
Consultation report
Operative report
Pathology report
Radiology report
Discharge summary
Emergency room
report
Psychiatric note
Special procedure
report
Chronological Record
Follows the patient over a period of
time
Each visit consists of a new entry by
date rather than by symptom or
diagnosis
One of the most common types of
medical records
This record sometimes make it more
difficult to catch diagnoses
Database
Problem list
Treatment plan
Progress notes
SOAP Charting
Method is distinct because of the four
parts of the approach
The POMR and SOAP methods can be
combined in one chart, making for a
very concise, clear set of information on
any patient
Filing
Vertical
Lateral
Movable
OSHA
Federal agency established in 1970
Purpose is to ensure safe work
environments for employees
Sets basic safety standards that all
institutions must follow
Violators of OSHA standards pay fines
In 1992 OSHA set a mandate that all
health care employers provide protection
from Hepatitis B to all employees
HIPAA
Contains privacy provisions that apply to
health information
For those institutions that transmit health
information electronically the following rules
must be followed:
Safeguards to protect integrity and
confidentiality of health information
Train personnel in how to protect the
confidentially of health information
Policies and procedures that provide protective
measures for the security and confidentiality of
information
Protected Information
Substance abuse
treatment records
HIV/AIDS
information
Mental health
records
Class Activity
Workbook: Medical Records: Applied
Practice
Procedure
Organizing a Patients Medical
Records
Summary
Topics Covered
Digital Session
Whats coming up in Module 4