A Day in the Life – Unit 8 Project Part I: A patient has just left the office after having an outpatient surgery procedure. As you get ready to put away the patient’s file, you realize that the patient has forgotten to take his prescriptions and after-care instruction sheets home with him. It is vital for proper healing and recovery for the patient to have these documents. You know you will have to contact this patient so you look inside for his contact information and signed HIPAA Release of Information form. 1. Under HIPAA, are you legally allowed to view this patient’s medical information?
Why or why not? Under HIPAA, I would not be legally allowed to view this patient’s medical information. As a certified medical assistant I am not able to view the patients file without having prior authorization. Today in most medical offices they have their personnel sign HIPPA and confidentially forms stating the rules and regulations of their position. This is to prevent HIPPA violations and confidentiality breeches. But sense the patient just had surgery he must have signed a records release form which then makes it okay to retrieve his contact information for this situation. 2.
In this case, how would you be able to correct your error and provide the missing documents and instructions to the patient while still protecting patient confidentiality under HIPAA? In a case where prior authorization has been given it would be okay to contact the patient and inform them of the situation. If prior authorization has not been established as a medical professional you would need to address the issue to someone who does have authorization to access the file and contact the patient. 3. Besides a HIPAA Patient Release of Information form, list 4 other items that are found in the medical record.
Doctors' Listening Skills When people go to the doctor's office they want the doctor to listen. Competency and a correct diagnosis are appreciated too, but more than anything, patients value doctors's i lence (Richards, 1407). In addition, patients want "more and better information about their problem and the outcome, more openness about the side effects of treatment, relief of pain and emotional ...
Other items that can be found in a medical record include things like progress notes or physician’s notes. Test results would be another thing that would be included in a medical record file. Insurance is an important asset that is included in almost every medical record. The insurance is included for billing purposes. Lastly a copy of patient identification card, social security number, and other information used to contact purposes such as address and phone number. 4. Legally, does the patient or the physician/healthcare facility own the medical record? Why?
In most states your health record is the physical property of the healthcare provider/facility but you as a patient also have rights. These rights are as follows: Review and/or have a copy of that record Ask to have your medical record corrected Not have your medical information disclosed to others unless you direct them to do so or unless the law authorizes or compels the physicians office to do so 5. List 3 ways patient confidentiality is maintained in the reception/waiting area of a medical office. There are many different ways a reception/waiting area of a medical office can help to maintain confidentiality.
One being, when calling a patient back to be seen only use their first names instead of their full name. Another would be, when the patients are signing in there should always be a way to cover up their names to avoid other patient from looking at their information. Lastly there should be a way that conversation is not heard by others in the waiting area, such as a portioned wall for example. 6. A breach of confidentiality can result in what consequences for a health care professional? Every doctor’s office or hospital has its own rules and standards for how to prevent breach of confidentiality.
VITAL SIGNS: Pulse 100, respiratory rate 42 per minute, temperature 99. 1, blood pressure 156/96. GENERAL: The patient appears very tired at the present time. HEENT: negative. CHEST: There is an increased anteroposterior diaemeter to the chest. No intercostal retractions during inspiration. HEART: Normal heart sounds without murmor or racing. ABDOMEN: soft and nontender. EXTREMETIES: normal with ...
They also have their own disciplinary acts. Some may give write ups or demote the employee. But worse case scenarios would involve a lawsuit or having to pay fines. Depending on the state some fine can reach up to $250,000. 00 depending on the type of confidentiality violation. 7. From the list of Interpersonal Ethics (found on page 12-13 of your text), please describe how any of those traits were demonstrated in your actions in this case scenario? A sense of accountability for my actions was taken with shows responsibility. A sense of responsibility can become weakened when one is faced with peer pressure.
So to stop and think about the rules and actions I must take before acting made it possible for me to be able to “answer” or be accountable for my actions. Justice was also demonstrated in this situation, by performing fairness in my actions, and not treating one patient differently then another. Justice entails that the same rules will apply to everyone. This means that as healthcare workers we cannot show favoritism with our patients or our coworkers. Part II: A few days later, you’re on the job and answering the phone while the physician you are working for and your office manager are at lunch.
The patient calls back to the office complaining of immense pain. Since you hate to see patient in pain, you pull the patient’s record and see that the physician has prescribed the patient pain medication in the past. Seeing this, you go ahead and order the same prescription for the patient. Later that day, you find out that the patient has suffered a cardiac arrest due to a medication interaction… 1. Would the action taken in this scenario be within your scope of practice for your chosen field? Why or why not? The action taken in this scenario is not within my scope of practice in my chosen field.
Because I am not a doctor you cannot prescribe a medication. This is in no way tolerable and could have serious consequences not only for myself but it could be potentially harmful to the patient. 2. What determines your scope of practice for your chosen career? Training, laws, legal systems, and the medical facilities rules or guidelines, are all what determines my scope of practice for my chosen career. Each of these differs from state to state and in each different medical facility. It is important to know your scope of practice and to stay up to date if any changes occur.
Should the use of marijuana for medicinal purposes be legalized? Wouldn't it be simple to provide a simple black or white answer to this question? Across the nation there is much debate on this very topic, one that I don't believe can be solved so easily with a yes or no. There are so many activists that have strong opinions on this subject and go to the fullest extent to ensure they are heard. As ...
3. Would Respondent Superior apply in this case scenario? Why or why not? Respondent Superior would not apply in this case scenario, because you were not given permission by the doctor or patient. Your actions were done alone without any kind of instruction form any superior of any kind. 4. Would the Good Samaritan Law apply in this case scenario? Why or why not? Good Samaritan Law would not apply in this case scenario, because the law is solely for patients who are in need of emergency care only. It protects health care professionals from being sued for malpractice or neglect.
In this case you could have informed the patient that you needed a doctor to submit the prescription because it you so not have authorization to do so. Or you could have instructed that the patient go to an emergency room to have another doctor administer the medication if it was and emergent situation. 5. What role does the Food and Drug Administration (FDA) play in regards to prescription medication? The FDA’s Office of prescription drug Promotion reviews and regulates and enforces prescription drug advertising and promotion through surveillance activities to all pharmaceutical manufacturers.
6. What role does the Drug Enforcement Agency (DEA) play in regards to prescription medication and a physician’s ability to prescribe narcotics? “Drugs that have a potential for addiction, habituation, or abuse are also regulated. The Drug Enforcement Administration (DEA) of the Department of Justice controls these drugs by enforcing the Comprehensive Drug Abuse Prevention and Control Act, more commonly known as the Controlled Substances Act of 1970. This act regulates the manufacture and distribution of the drugs that can cause dependence.
Physicians who administer controlled substances, also called narcotics, must register with the DEA in Washington, DC, and the registration must be renewed every three years. A DEA registration number is assigned to each physician. A physician who leaves the practice of medicine must return the registration form and unused narcotic order forms to the nearest DEA office. An accurate count of all narcotics must be kept in a record such as a narcotics log, and all narcotics records must be kept for two years.
Gun Control Americans are faced with an ever-increasing problem of violence. The streets of America are now a war zone. Teenage gangsters murder one another for drug territory, and innocent victims are caught in the crossfire. However, most recent and most abhorrent, is our children are killing one another. They are killing with extreme prejudice. Our children are killing, exhibiting little or no ...
The date and person to whom the drug was administered, along with the signature of the person administering the drug, are recorded. In some states, physicians who prescribe narcotic drugs but do not administer them, such as dentists and psychiatrists, are also required to maintain narcotics logs and inventory records. Most states limit the administration of narcotics to physicians and nurses. States may be more restrictive, but not less, than the federal government when regulating the administration of controlled substances.
For example, a state may require physicians to keep controlled substances records for a longer period of time than the federal regulations require. All narcotics must be kept under lock and key. If a controlled (narcotic) drug needs to be “wasted,” or destroyed, it should be poured down a drain or flushed down a toilet. Two people should be present when controlled substances are destroyed. ” (Fremgen, B. (2008).
Medical Law and Ethics, 3rd Edition, page 162)