HIPAA & Patient Confidentiality
This federal law enacted in 1996 protects sensitive patient health information from being disclosed without the patient's consent or knowledge.
What is HIPAA (Health Insurance Portability and Accountability Act)?
This document, established by state regulations and facility policies, defines the specific duties, tasks, and boundaries a PCT is legally permitted to perform.
What is the Scope of Practice?
This foundational patient right guarantees that a competent adult patient can decline any medical treatment, test, or procedure at any time.
What is the Right to Refuse Treatment?
This medical order instructs healthcare providers NOT to perform cardiopulmonary resuscitation if the patient's breathing or heartbeat stops.
What is a DNR (Do Not Resuscitate) order?
PCTs are legally categorized as this type of professional, meaning they are required by law to report suspected abuse, neglect, or exploitation of vulnerable patients.
What is a mandated reporter?
This specific term describes any individually identifiable health information created or received by a healthcare provider, including names, dates, and medical records.
What is PHI (Protected Health Information)?
Threatening to apply restraints or force-feed a patient against their express will constitutes this intentional tort.
What is assault?
This legal document outlines a patient's expectations, including respectful care, privacy, clear communication, and access to their medical records.
What is the Patient's Bill of Rights?
This legal document allows an individual to state in advance what medical measures should or should not be taken to prolong life if they become terminally ill.
What is a Living Will?
If a PCT observes a colleague working under the influence of drugs or alcohol, the PCT’s ethical and legal obligation is to take this action immediately.
What is reporting the observation immediately to the supervisor/charge nurse?
A PCT posts a photo on social media after a shift showing a patient's room and room number in the background. Even though no name was mentioned, this action constitutes a violation of this legal principle.
What is a HIPAA breach/violation (or invasion of privacy)?
Performing physical care or touching a patient without receiving their permission—or proceeding after they explicitly refuse—constitutes this intentional tort.
What is battery?
While a physician must obtain formal informed consent, a PCT relies on this type of consent when a patient willingly extends their arm for a blood pressure cuff or venipuncture.
What is implied consent (or expressed consent)?
This specific advance directive designates a trusted person (surrogate) to make healthcare decisions on the patient's behalf if the patient loses decision-making capacity.
What is a Medical Power of Attorney (or Durable Power of Attorney for Healthcare)?
This internal administrative document must be completed whenever an unexpected event occurs that causes—or could have caused—injury to a patient, visitor, or staff member.
What is an Incident Report (or Event/Occurrence Report)?
This HIPAA rule specifically requires healthcare facilities to implement physical, technical, and administrative safeguards for electronic protected health information (ePHI).
What is the HIPAA Security Rule?
If a PCT fails to raise side rails for a known fall-risk patient, causing the patient to fall and suffer an injury, the PCT can be held civilly liable for this tort.
What is negligence (or professional malpractice)?
When a patient signs a form acknowledging they understand the risks, benefits, and alternatives of a invasive medical procedure before it is performed, this process has occurred.
What is informed consent?
If a patient with a documented, valid DNR order goes into cardiac arrest, the PCT's immediate correct legal action is this.
What is withholding CPR and immediately notifying the charge nurse/physician?
An incident report should contain objective facts and observations, but it should NEVER be documented in this official record.
What is the patient's Electronic Health Record (EHR / Medical Chart)?
Under HIPAA, a PCT is only permitted to access or view the electronic medical record of a patient if they have this specific operational justification.
What is a direct "need-to-know" / direct involvement in the patient's immediate care?
Improperly detaining a patient, locking them in a room, or using unapproved physical/chemical restraints without a valid physician's order constitutes this tort.
What is false imprisonment?
When a patient with decision-making capacity chooses to leave the hospital against medical advice, they are asked to sign an AMA form. "AMA" stands for this phrase.
What is Against Medical Advice?
This term describes the legal and ethical doctrine that respects a patient's right to self-determination regarding their healthcare decisions.
What is autonomy (or patient autonomy)?
This ethical principle, often paired with beneficence ("doing good"), directly translates to "first, do no harm" in healthcare delivery.
What is non-maleficence?