Medical Law and EthicsMedical Law and EthicsLesson 3:Lesson 3:Documentation and RegulationsDocumentation and Regulations

Lesson ObjectivesLesson ObjectivesLesson 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.

DocumentationDocumentation

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 Information Documented in a Patient’s ChartPatient’s Chart

Calls and visitsTreatmentsNo-showsAppointment

cancellationsMedicationsPrescription

refillsVital signsOther pertinent

information

Cautions with DocumentationCautions with DocumentationBe careful with fax transmissions

of medical recordsReceiving fax must be located in

a restricted areaA disclaimer should be placed on

the fax cover explaining that records are confidential

Court TestimonyCourt TestimonyIf 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 ProvideReports Physicians Must Provide

BirthsStillbirthsDeathsCommunicable illnesses or diseasesDrug abuseCertain injuriesAbuse of child and adultsGunshot and knife woundsAnimal bites

Mandated ReporterMandated ReporterMust report abuse or risk fines

and/or jail time

Child AbuseChild 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

Elder AbuseElder AbusePhysicians have a duty to report

questionable injuries of the elderly

These requirements include:◦Physical abuse◦Neglect◦Abandonment

Requirements differ by state

Drug AbuseDrug 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 224Form DEA 224Used by physicians to register

with the DEAAllows physicians to prescribe,

dispense, or administer controlled substances

Renewal is required every 3 years

Requirements for Controlled Requirements for Controlled SubstancesSubstancesControlled drugs must be kept in

a double-locked cabinetAny theft must be immediately

reportedPhysician’s black bag and

prescription blanks should always be stored in a secure, locked location

Schedule for Controlled Schedule for Controlled SubstancesSubstancesSchedule I (cocaine, LSD)

◦ Highest potential for addiction and abuseSchedule II (Morphine)

◦ High potential for addiction and abuseSchedule 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 AssistantRole of the Medical AssistantDoes not dispense controlled

substancesMust be knowledgeable about

the regulations of the drugsOnly licensed personnel are

permitted to dispense drugsAlways report any unusual

patient behavior indicating addictive drug use

If you are aware of illegal activity and remain silent, you may be liable.

MA’s Role Related to MA’s Role Related to Confidentiality/Privacy IssuesConfidentiality/Privacy IssuesNever 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 MA’s Role Related to Confidentiality/Privacy IssuesConfidentiality/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 MA’s Role Related to Office ManagementManagement

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 MA’s Role Related to Office ManagementManagementNever 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 MA’s Role Related to DocumentationDocumentationCarefully sign or initial every notedocument the no-show’sDocument referrals to another

physicianFollow up to make sure the patient did

see the referral physician

MA’s Role Related to MA’s Role Related to DocumentationDocumentation

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 MA’s Role Related to DocumentationDocumentation

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 MA’s Role Related to Drug RegulationsRegulations

May administer medication only under the direct supervision of a physician

Follow the Controlled Substances Act

Know state lawsSecure the supply of

prescription pads from theft at all times

MA’s Role Related to Drug MA’s Role Related to Drug RegulationsRegulations

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 MA’s Role Related to Certification and Licensingand 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 MA’s Role Related to Informed ConsentConsent 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 IssuesMA’s Role Related to Safety Issues

Maintain a safe environment

Report any safety hazards at once

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Medical Ethics