questions
What should be written in a medical record?
What is necessary to carry out functions of the business or government agency collecting the info
A legal defense that holds that the defendant is not guilty of a negligent act because the plaintiff knew of and accepted beforehand any risks involved.
assumption of risk
A program of measures taken by health care providers and practitioners to uphold the quality of patient care.
quality improvement (QI) or quality assurance (QA)
Difference between electronic medical record (EMR) and electronic health record (EHR)?
EHR is to share info with other health care providers in one electronic platform.
EMR is to track data overtime, monitor certain parameters (BP, Vaccines) and monitor and improve quality of care.
Courts have held that in some cases, patients treated for mental or emotional conditions may be harmed by seeing their own records.
True
What are the guidelines for correcting errors in medical record?
In a paper record, draw a line through the incorrect information so that it is still legible. Write in the correct information. Sign or initial, date, and time the entry. If possible, ask another staff member to witness the correction. The electronic record addresses a correction using either the addendum or amendment process.
An affirmative defense that alleges that the plaintiff, through a lack of care, caused or contributed to his or her own injury.
contributory negligence
Defenses used in a lawsuit that are based on legal technicalities.
technical defenses
The electronic systems health care professionals—and increasingly, patients– used to store, share, and analyze health information.
health information technology (HIT)
Photographing or otherwise recording a patient's image without proper consent may be interpreted in a court of law as invasion of privacy.
True
What could be the consequence of failing to appear in the court in case you have been subpoenaed for some reason?
contempt of court charges, punishable by fines or imprisonment
An affirmative defense claimed by the defendant, alleging that the plaintiff contributed to the injury by a certain degree.
comparative negligence
That period of time established by state law during which a lawsuit may be filed.
statute of limitations
What does HIPAA stand for ?
Health, Insurance, Portability, Accountability, Act
A physician claims that a patient was negligent in following her treatment plan and caused her own injury. This type of defense is known as assumption of risk.
False!
-Describing contributory negligence
Time period for statue of limitations?
1 to 6 years, with 2 years
Defenses used by defendants in medical professional liability suits that allow the accused to present factual evidence that the patient’s condition was caused by some factor other than the defendant’s negligence
affirmative defenses
A technical defense that prohibits a lawsuit against the person who caused an injury (the tortfeasor) if he or she was expressly released from further liability in the settlement of a suit.
release of tortfeasor
The remote delivery of health care services and clinical information using telecommunications technology.
telemedicine
Dr Strange was obligated to see all patients who enter the ER he worked at under standard of care
FALSE!
-Obligated = duty of care
-Standard of care= expected
What should NOT be written in a medical record?
Anything not necessary for carrying out functions of the job.
Think of discussion board with Seinfield episode calling Elaine difficult.
A defense that claims innocence of the charges or that one or more of the four Ds of negligence are lacking.
Denial
The taking of steps to minimize danger, hazard, and liability.
risk management
A law that allows for individuals to bring civil actions on behalf of the U.S. government for false claims made to the federal government, under a provision of the law called qui tam (from Latin meaning “to bring an action for the king and for oneself”).
Federal False Claims Act
Affirmative defenses require the defendant to show evidence the patient's problem is due to something else besides negligence on the defendant's part
True