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Module 3

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

Characteristics of Ethical Standards


Typically more severe than those
standards required by law
Often more demanding than the law
A violation of an ethical standard
could mean the loss of the
physicians reputation

Principles and Standards of Care


Medical Assistants
Allied Health Professionals

AMA Actions for Ethical Violations


AMA takes violations very seriously!
AMA may:
Investigate the member in confidence
Conduct an investigative hearing
Reprimand or admonish the member
Place the member on probation
Suspend the member
Expel the member

AMA cannot take legal actions for


ethical violations

Read the AMA Principles in its entirety by visiting www.ama-assn.org

State Medical Board Actions for


Ethical Violations
When an ethical complaint is made
against a licensed physician to a
state medical board, the board may:
Limit the physicians practice
Warn the physician
Revoke the physicians license to
practice medicine in the state
If it is alleged that a physician has committed a criminal
act, the medical society must report it to the state board.

Pledge Made Under the AAMA


Code of Ethics
A.
B.

C.
D.
E.

Render service with full respect for the dignity of


humanity;
Respect confidential information obtained through
employment unless legally authorized or required by
responsible performance of duty to divulge such
information;
Uphold the honor and high principles of the
profession and accept its disciplines;
Seek to continually improve the knowledge and skills
of medical assistants for the benefit of patients and
professional colleagues;
Participate in additional service activities aimed
toward improving the health and well-being of the
commModuley.

Creed of the AAMA


I believe in the principles and purposes of
the profession of medical assisting.
I endeavor to be more effective.
I aspire to render greater service.
I protect the confidence entrusted to me.
I am dedicated to the care and well-being
of all people.
I am loyal to my employer.
I am true to the ethics of my profession.
I am strengthened by compassion,
courage, and faith.

As a Medical Assistant, You Are


NOT Expected to.

Diagnose medical conditions


Interpret results of tests
Prescribe medications
These responsibilities are within the
physicians standard of care
An MA must take caution to not do anything
for which he or she is not trained and remain
within the scope of his or her practice.

The Patients Bill of Rights


Developed by the American Hospital
Association
Describes the patient-physician
relationship
MAs must also follow these guidelines
when working with the physicians
patients
Most medical offices have these printed
for patients

Patient Rights Specified by the


Medical Patients Rights Act
All patients have the right to have their
personal privacy respected and their medical
records handled with confidentiality.
Information such as test results, patient
histories, or that a person is even a patient
cannot be told to another without permission.
No information can be given over the phone
without permission.
No records can be given to another person or
physician without permission.

Medical Ethical Issues


When should life
support be withdrawn?
When does a life begin?
Should abortion be
lawful?
Should partial abortion
be lawful?
Is euthanasia ever
permissible?

Medical Ethical Issues


Should an unborn baby be sacrificed to save the mother?
What are the ethical issues associated with artificial
insemination?
Should couples use fertility drugs to increase their chances
of pregnancy?
Should eugenic sterilization be allowed?
Should sterilization be allowed as a form of birth control?
Should genetic testing and counseling be something that
every couple or parent should undergo? What are ethical
considerations surrounding wrongful life issues?
Should we be able to clone tissues, organs, or organisms?
Where does one draw the line?
Should human stem cells be used to treat certain
diseases?
Others?

Class Activity
AMA Code of Ethics

Managing Medical Records

The Medical Record


Patients past
medical records
History and physical
Insurance
information
Office notes
Progress notes
Telephone messages
Pathology results
Nursing notes

Medications
Physician orders
Radiology reports
Laboratory reports
Operative reports
Consultation
reports
ECGs
Miscellaneous

Contents of Medical Records

Consultation report
Operative report
Pathology report
Radiology report
Discharge summary
Emergency room
report
Psychiatric note
Special procedure
report

Information that SHOULD NOT be


Included in a Patients Chart
Your opinions
Internal office
problems
Subjective
comments

Contents that SHOULD BE


Included in the Medical Record
Factual (objective)
statements
Everything that is done
during a patients
medical visit, ordered
over the telephone, or
discussed with a
patient over the
telephone or
e-mail
Legible writing in black
ink

Contents of Medical Records

Patient registration form


Family and medical history form
Form to chart physical examination results
Results of all tests performed on the patient
Records from referring physicians or
hospital visits
Informed consent forms
Diagnosis and treatment plan
Patient correspondence

Formats for Recording Medical


Information
Chronological
record
Problem-oriented
medical record
Source-oriented
medical record

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

Problem-Oriented Medical Record


Developed by Dr. Lawrence Weed in 1970
Used to identify patient problems and chart
by those problems
The functional aspect of this type of
charting is the patient problem list found at
the front of the chart
As new problems and diagnoses are
identified, they are noted on the problem
list, helping the health care provider to
identify trends

Sections of the Problem Oriented


Medical Record

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

Source Oriented Medical Record


Common method utilized in medical clinics
Patient information is placed in the medical
record in reverse chronological order and
organized in different sections
Each office determines which sections are to
be used and in what order they are to
appear in the medical chart
The sections commonly used include history
and physical, insurance, progress notes,
medications, laboratory, and consultations

How to Correct an Error in the


Medical Record
Do not erase or totally
obliterate the original
error with commercial
products such as
correcting fluid
Draw a single line through
the error so the original
entry can still be seen
Initial above the single
line
Date and write error
Once this is complete,
write in the correction

Steps for Adding Items to a


Patients Chart
An item is added to a patient record as soon as it
is discovered that the item was omitted
Locate the last entry in the medical record
Using a pen with black ink, on the next line of the
record, immediately after the last entry, place the
current date
On the same line, after the date, place the
statement, Late entry
Note the date on which the information to be
added was gathered
Enter the information that was originally omitted
Sign the entry with your full name and credentials

Guidelines for Changing Items in a


Patients Record
Locate the incorrect information
Using a pen with black ink, draw one single
line through the incorrect information, so that
the incorrect information is not obscured, but
can still be read
Never erase entries in a medical record
Never use correction fluid in a medical record
Never mark through information so that it
cannot be read
Place the date of the correction, your initials,
and error above the incorrect information
Enter the correct information

Filing
Vertical
Lateral
Movable

Quality Assurance for Quality


Medical Care
Goal is to improve
quality of care
Implementation
requires
developing patientcentered criteria
One method to
document problem
areas is the use of
incident reports

Purpose of an Incident Report


Report should be completed whenever
there is an unusual occurrence, such as a
fall, error in medication dispensing,
needlesticks, fire, or patient complaint
Purpose is to document exactly what
happened with the goal of preventing
another episode
Details on completing an incident report
are usually included in every offices
procedure manual

Interventions to Ensure Quality of


Patient Care
The Joint Commission
Occupational Safety and Health
Administration (OSHA)
Health Insurance Portability and
Accountability Act (HIPAA)
Lets take a closer look at each one of
these!

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

Release of Medial Records


Physician owns the
medical record
Patient has the
legal right to
access the record
To authorize release
a release form must
be signed by the
patient, parent,
legal guardian, or
agent

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

Disclosure Without Consent


Instances when medical records can be released
without consent include:
When records are needed by health care workers for
the care of the patient
For qualified individuals who perform tasks such as
data processing, medical record transcription, and
microfilming

Instances when medical records can be released


without consent include:
Government agencies who investigate or regulate
health issues such as child abuse and communicable
diseases
Lawyers and parties involved in a law suit related to
the patients medical condition

Options for Storing Medical


Records
The medical office
building
Another office or
building near to the
medical office
A business that
specializes in
housing records

Ownership of Medical Records


If a patient requests to view their own
medical record, access must be allowed
unless the physician determines it may be
detrimental
Prior to allowing the patient to view their
record, the MA must first check with the
physician or office manager for approval
Never leave the patient alone with their
record

Guidelines for Retaining Medical


Records
To be absolutely safe, medical records
should be retained forever
Legal statues to keep records and
documents vary by state
The standard set by most states for
keeping records is 2-7 years after the
last treatment, or seven years after the
patient reaches the age of majority
The AMA recommends keeping records
for 10 years

Issues Addressed in a Medical


Record Destruction Policy
Length of time records are kept
Where records will be kept
Person responsible for deciding what
to keep and what to destroy
Method used for documenting
destruction of records
Method of disposal

Class Activity
Workbook: Medical Records: Applied
Practice

Small Group Work


On the Job scenario

Role Play Activity


Professionalism, documentation, and
communication skills

Procedure
Organizing a Patients Medical
Records

Summary
Topics Covered
Digital Session
Whats coming up in Module 4

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