Writing "the patient is very annoying", erasing or using correction fluid to correct a note in chart, leaving a chart open on a desk
What are things you should never do with a medical record?
100
Death in which heart has stopped functioning; considered a legal death
What is cardiac death?
100
Submitting a dispute for resolution to a person other than a judge
What is arbitration?
200
Admitting diagnosis, evidence of a physician exam, documentation of complications, signed consent forms, consults, lab reports/md notes, and discharge summary
What are JCAHO minimum requirements for a medical record?
200
Allowing a patient to die naturally; this is also a legal act
What is passive euthanasia?
200
A defense, similar to contributory negligence, that the plaintiff's own negligence helped cause the injury; not a complete bar to recovery of damages but only receives a portion of damages
What is comparative negligence?
300
Documenting in a timely manner and with complete entries can help physicians defend themselves if they are charged with this
What is malpractice?
300
Measures to assess quality of life, such as general health, mental health, physical functioning
What are quality of life indicators?
300
Latin phrase meaning "the thing speaks for itself"
What is res ipsa loquitor?
400
If releasing information from a patient chart to a third party you must have this
What is the patient's written consent?
400
This type of care is focused on providing comfort measures, emotional support, and a pain-free environment
What is hospice?
400
The failure to perform an action when its necessary
What is nonfeasance?
500
Before destroying records, one should check make sure they are in compliance with these
What are state laws?
500
Living will, durable power of attorney, DNR orders are examples of this