Term
| Texas Medical Practice Act |
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Definition
| "all records pertaining to the history, diagnosis, treatment or prognosis of a patient.'' – any paper, images etc. 80-90% of the reason there is a medical record is for billing to prove you did what you said you did |
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Term
| What defines a “medical record” |
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Definition
- Documentation of healthcare services
- Individually identifiable data in any medium
- However, does not include records that are not official (PHR – Microsoft or Google has these, this does not count, something the patient creates and posts online…) |
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Term
| Medicare COP (Medicare condition of participation) |
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Definition
this also defines what must be in the Electronic health record… Must include:
Admitting diagnosis, PE, health history(within 7 days of admission), documentation of any complication (HAI, never event or medication reaction), Signed consent forms for any treatments or procedures, Consultation reports, provider notes, treatment reports medication records, x-ray, lab reports DC summary |
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Term
| Who “owns” the Medical Record |
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Definition
- Patients control the dissemination of information (except TPO)
- Who owns the medical record? So, the rule is that the DOCTORS own the data –but the patient owns dissemination of data except TPO |
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Term
| Red Flags in Health Record |
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Definition
Illegibility
Vague terminology
Criticism of other professionals
Omissions of dates /times
Countersignatures
Abbreviations
Opinions
Delayed entries
Inconsistencies
Corrections
Lack of informed consent
Improper alteration of records
Cloning a document (copying and pasting)
IVCOCA - ODICLIC |
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Term
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Definition
| In law a person is liable when they are financially or legally responsible for something |
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Term
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Definition
No one regulates EHRs so you could argue that through the certification process
It’s a voluntary process – you could build your own, buy one out of someone’s truck unless you’re taking
Medical patients |
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Term
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Definition
| Vendor’s liability to the Practice for any losses in contract, tort, or otherwise, arising out of the subject matter of this Agreement shall be limited those actual and direct damages which are reasonably incurred by the Practice and shall not exceed the fees paid by the Practice over the months in which the liability occurred, not to exceed twelve (12) months. Vendor will not be liable for special, punitive, indirect, incidental, exemplary or consequential damages or loss of data, lost profits, loss of goodwill in any way arising from this Agreement, even if the Vendor has been notified of the possibility of such damages occurring. “ |
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Term
| Medical Device liability / product liability |
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Definition
| Law holds medical device companies may not be liable for device problems after device approved by FDA |
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Term
| You need these things to prove Malpractice and Negligence |
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Definition
| Duty, Dereliction, Direct Cause and Damages |
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Term
| Malpractice and Negligence: Duty |
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Definition
| Duty exists when the physician-patient relationship has been established. The patient has sought the assistance of the physician, and the physician has knowingly undertaken to provide the needed medical service. |
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Term
| Malpractice and Negligence: Dereliction |
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Definition
| Dereliction, or failure to perform a duty, is the second element required. There must be proof that the physician somehow neglected the duty to the patient. |
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Term
| Malpractice and Negligence: Direct Cause |
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Definition
| There must be proof that the harm to the patient was directly caused by the physician's actions or failure to act and that the harm would not otherwise have occurred. |
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Term
| Malpractice and Negligence: Damages |
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Definition
| The patient must prove that a loss or harm has resulted from the actions of the physician. |
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Term
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Definition
| Negligence is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances. The area of tort law known as negligence involves harm caused by carelessness, not intentional harm. |
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Term
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Definition
| means both the defendant and person bringing harm contribute to the bad thing person drunk hit person who was driving crazy across the centerline so both contributed to accident/partially at fault (courts are getting away from this and going more toward comparative negligence) |
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Term
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Definition
- Patient contributed to negligence by not following medical standard (courts I will say give you 75% of reward b/c other was 75% responsible)
- Damages (can be awarded proportionally) |
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Term
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Definition
- “The thing speaks for itself”
-Foreign bodies left in during
surgery
-Burns from heating modalities
-Injuries to body outside field of treatment
-Three requirements
-Act of negligence under defendants control
-Patient must not have contributed to the act
-Pt would not have been injured if reasonable care had been used |
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Term
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Definition
A person who in good faith administers emergency care at the scene of an emergency or in a hospital is not liable in civil damages for an act performed during the emergency unless the act is willfully or wantonly negligent.”
Does not apply to healthcare workers who are on the job |
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Term
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Definition
| Physician is “covered entity” responsible for maintaining accurate pt records |
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Term
| 4 necessary components of contracts!!! |
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Definition
Consideration
-Something of value is bargained for
Agreement
-Communicated, good faith, not under duress
-Clearly define expectations of both parties
Legal activity
Contractual capacity
CALC |
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Term
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Definition
Prohibits physicians from making referrals to an entity for certain designed health services (DHS) covered by the Medicare program if the physician has a financial relationship with the entity – if you have a medical stake in it can’t make referral
Exceptions describe financial relationships with entities to which physicians make referrals that will not violate the Stark law – for example if show that its cheaper for them to reimbursed from Medicare if do this but generally cant |
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Term
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Definition
| I as a hospital can’t induce you to send me patients by giving you a gift – I’ll give you a boat, build you a new office building, give you some cash etc. |
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Term
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Definition
| AKS violation Is criminal and violation of Stark law is only civil penalty. |
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Term
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Definition
- Privileged communication exists between physician and patient – “Confidential” that can’t be subpoenaed in court
- Does not extend to nurses, MAs, office staff, etc
- Privileged communication cannot be used as evidence in a civil or criminal trial |
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Term
| Limits on Physician’s Right to Refuse Patients – Must treat these! |
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Definition
- Medical emergencies
- No right to discriminate on the basis of race, gender, sexual orientation, gender identity, HIV status
- Cannot refuse to treat someone they have a contractual obligation to treat |
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Term
| Physician’s Right of Conscience |
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Definition
| Physicians saying I can’t do this (abortion, contraception etc.) because of right of conscience but ethically physician has to say I will send you over to someone who can do it |
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Term
Emergency Medical Treatment and
Labor Act (1986) (EMTALA) |
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Definition
This used to be practice where ambulance drivers would pick someone up and drive them to ER and dump patients that
could not pay their bill – basically this law says you have to evaluate them And at minimum determine what their health status iis. If they aren’t stable and can’t pay you have to send them somewhere who can |
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Term
| Medical Device Liability: Liability Types |
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Definition
1. Defectively manufactured medical devices
2. Medical devices with a defective design (even though properly manufactured), or
3. Defectively marketed medical devices |
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Term
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Definition
refers to the coordination of care(including joint contracting) across (different organizations) a continuum of services, including preventive, outpatient, inpatient acute hospital care, post-acute including skilled nursing, rehabilitation, home health services, and palliative care to improve the value of the care provided.
Requires: Collaborative Leadership, Aligned Incentives, Clinical programs, Technology Infrastructure |
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Term
| HB 1107 passed Texas House May 12, 2017 |
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Definition
- Physician may establish a doctor – patient relationship solely on the basis of a telemedicine visit
- Standard of care must be the same as in-person services
- Prescribing to be addressed by TMB, Board of Nursing, Board of Pharmacy to establish rules. Must acknowledge Dr – Pt relationship
- Health plan must adopt payment policies for telemedicine visits
- Health plans may not exclude TM visits from coverage
- Disallows prescribing of drugs or devices that terminate pregnancy |
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Term
| Office of National Coordinator of Health IT |
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Definition
| The ONC’s mission involves many aspects of health information technology (HIT), including policy coordination, strategic planning for the adoption of health IT and health information exchanges (HIE), establishing governance for the Nationwide Health Information Network and, above all, promoting a national health IT infrastructure. |
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Term
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Definition
| Largest Healthcare payer in the U.S, Oversees EHR incentive programs, Oversees PQRS, Oversees MACRA/MIPS |
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