Term
| Healthcare Quality Improvement Act of 1986 |
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Definition
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Term
Physician Professional Review
-National Practitioner’s Data Bank
-Effective September 1, 1990
-PURPOSE |
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Definition
| To encourage greater efforts in professional peer review and to restrict the ability of incompetent practitioners who move to avoid discovery |
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Term
| Reporting is Applicable to: |
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Definition
Hospitals
Healthcare entities
Boards of Medical Examiners
Professional Societies of Physicians, Dentists and others |
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Term
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Definition
Limited immunity for MDs in Peer Review
National reporting of final Peer Review activities finding INCOMPETENCE to DHHS
Failure to report results in withdrawal of immunity
Establishment of national data bank
Reporting to State licensing boards |
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Term
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Definition
-Hospitals are required to request information from the national data bank regarding each healthcare provider that applies for clinical privileges
-Every two years, a hospital must request information regarding each physician which already has clinical privileges at a hospital. Failure to do so presumes that the hospital has knowledge of information contained in the data bank. |
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Term
HCQIA Revised: 2004
-Safe Healthcare Reporting Act of 2004
Requirements: |
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Definition
State licensing boards are to report to the National Practitioner Data Bank
Any sanctions of a physician or healthcare practitioners
known instances of healthcare entities failing to report required information
Healthcare entities to report actions that adversely affect clinical privileges
Health care entities to request information on those who apply for medical staff or clinical privileges |
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Term
HCQIA Revised: 2004 (cont)
Safe Healthcare Reporting Act of 2004
Requirements continued: |
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Definition
State licensing boards are to report to the National Practitioner Data Bank
Provides immunity from civil liability for health care professionals who disclose information about employees
Allows for fines for violations of reporting requirements
Amends Social Security Act to require states to implement a system to report criminal background check information to the Data Bank |
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Term
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Definition
| Voluntary agreement by a person to make an intelligent choice or to do something proposed by another |
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Term
| Treatment Without Consent |
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Definition
Failure to obtain consent for treatment could result in tort action
Assault and Battery
Fraudulent consent = no consent
–Misrepresentation of fact’
–Fraud |
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Term
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Definition
Signer knows what he/she is signing, knows what is to be done and understands the risks involved. Informed consent for surgery/procedure also includes alternatives.
Responsibility of the physician to be sure that informed consent is obtained prior to surgery
HIM responsible for consents being on the chart |
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Term
Informed Consent (cont)
What is included |
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Definition
Name of hospital and physician
name of patient
Statement of nature of operation
Authority to perform additional operations or procedures necessary based on judgment of the surgeon
Consent to dispose of tissues removed
Statement of risks and alternatives
Signature of patient or authorized person
Signature of witness
Date of signature |
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Term
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Definition
Consent by implication or deduction from the circumstances
Covers consent in emergencies
Physician office |
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Term
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Definition
Expressed category of consent given directly
–Written – voluntary consent written down and signed by the patient
–Oral - voluntary consent, established by proof of conversation between physician and patient |
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Term
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Definition
Not recommended – consent form which does not identify specifics
Often referred to as a blanket consent for “any and all” treatment
In Oregon not valid for surgical procedures |
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Term
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Definition
The written consent is not valid if when the patient signed the consent he/she was intoxicated
Blanket consent is of doubtful value
Good idea to have consent witnessed – witness can verify patient was of sound mind
Surgery resulting in sterility – consent should be signed by the spouse (not required) |
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Term
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Definition
When a patient is conscious or unresponsive
Instances of threat to:
–Life
–Health of patient
–Medical necessity for acting without consent is well documented
–A form of implied consent
Duty to use: diligence, attention, good judgment, and expertise
Form, Document. Policy |
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Term
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Definition
Court Intervention for Minors
Treatment illegal without consent from parents (except emergencies)
Court can (depending on state) order an operation
–appoint guardian in loco parentis
Court hearings (testimony)
Court approval – appoints temporary guardian ( neighbor, relative, friend, administration)
The consent of a minor to medical or surgical treatment is ineffective; the physician must secure consent of the parent or someone standing in loco parentis otherwise risks liability – |
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Term
Emancipated Minor
Consenting means
Established through: |
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Definition
parents are no longer responsible for minor Established through:
–Marriage
–Minor living away from parents and self supporting
–Consents for minors in Oregon:
Age 15 for treatment
Any age for venereal disease
Any age for birth control
16 to give blood |
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Term
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Definition
–Rights/Responsibility Issues: Patient rights – Refusal of treatment
Document carefully.
Written refusal should be obtained if possible.
In hospital and nursing policy and procedures manual.
Form, Document, Policy |
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Term
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Definition
Leaving Against Advice
AMA Release Form
If a patient refuses treatment for any reason it must be noted in the medical record and a release form signed.
If patient refuses to sign release – note in the medical record and seek advice of legal council if AMA release is injurious to the patient.
Establish policy.
Leave of Absence: Form, Document, Policy |
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Term
| Disclosure of Patient Information |
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Definition
| DO NOT release information from a patient’s medical record, except when specified by law or facility policy, without the written authorization of the patient, the guardian in the case of a minor, the Power of Attorney for health care in the case of an incompetent person, or the next of kin or executor of the estate in case of death. |
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Term
Internal Release of Information
-Oregon |
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Definition
| –Recommendation regarding continuing care: Request release information to outside facility in non-emergency situations but the transfer of information should not be delayed waiting for release/ |
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Term
| Guidelines for Release of Information |
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Definition
| Do not disclose any information about a patient to a third party without a signed consent. This extends to insurance companies, attorney and friends or family. It includes acknowledging whether or not the person is a patient. |
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Term
| Guidelines for ROI (cont) |
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Definition
| Do not decide confidentiality on the basis of whether or not you approve or agree with the views or morals of the patient. |
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Term
| Guidelines for ROI (cont) |
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Definition
| Do not review financial information about a patient. Be discreet when revealing a patient’s account balance orally. |
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Term
| Guidelines for ROI (cont) |
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Definition
When talking on the telephone, do not use the caller’s name if others in the room might overhear
-Use caution in giving the results of medical tests to patients over the phone or when leaving messages
- Do not leave medical charts or insurance reports out where patients or medical facility visitors can see them
See that confidentiality protocol is duly noted in the policy and procedure manual |
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Term
| Guidelines for ROI (cont) |
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Definition
If a patient is unwilling to release privileged information, the information should not be released. Exceptions include legally required disclosures:
Subpoenas
Statute to protect public health or welfare
Necessary to protect welfare of patient or third party |
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Term
| Guidelines for ROI (cont) |
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Definition
| Follow all regulations and procedures for safeguarding the confidentiality of electronically created stored and transmitted records, including passwords and level of access |
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Term
| 10 point Consent for Release of information |
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Definition
| 1.who is to Release the Information 2.Who is to receive the information 3.Name of Patient 4.Description of information to be released 5. purpose of request 6.revocation of statement"consent is subject to revocation except to the extent that action has been takin in reliance upon consent 7.signature of Patient 8.date consent is given 9.time period consent is valid 10. redisclosure statement |
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