How should the documentation of a patient's informed refusal be?
When a patient is noncompliant with the treatment plan, a member of the treatment team should: a. tell the patient that the doctor will no longer be able to treat him if he does not comply with the treatment plan and follow instructions. b. describe outcomes if the patient follows the recommended treatment.
What are the rights of a patient refusing medical treatment?
Documentation components required by Medicare include. evaluation; plan of care (POC, also called treatment plan) diagnoses, long-term treatment goals, type (e.g., group, individual), amount, duration, and frequency of therapy services; treatment notes; progress reports;
What documentation do I need to provide to provide medical treatment?
Nov 05, 2017 · Document your assessment of the patient immediately afterward. This is particularly relevant in the case of medication errors. Make note of who was notified about the mistake. For example, the patient themselves, the relatives, and the treating consultant. Lastly, document if you lodged an incident report. The discharge summary
How is information left out of dental records treated in court?
completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which
Which of the following information is included on a patient encounter form?
Although encounter forms can differ based on company, facility type, and services offered, they will generally include the following information: Patient profile (including patient name, date of birth, billing information, insurance information, etc.) Clinical observations (including diagnosis and diagnosis codes)Apr 8, 2021
What is the status of a medical record if the patient has passed away?
When a patient dies, their legal representatives, legal heirs, or close relatives have the right to access their medical records – upon written request. This allows them to know the cause of death or the specificities of their treatment.Jan 28, 2021
Which of the following has have established laws to provide patients access to their medical records?
With limited exceptions, the HIPAA Privacy Rule (the Privacy Rule) provides individuals with a legal, enforceable right to see and receive copies upon request of the information in their medical and other health records maintained by their health care providers and health plans.
Which of the following forms is used for billing purposes and must be attached to the patient's chart for the provider to complete?
which form is used for billing purposes and must be attached to the patient's chart of the provider to complete ? The provider records the diagnosis and procedures preformed during a visit on the encounter form. It should accompany the patient's chart.
How do you document a deceased patient?
Document the disposition of the patient's body and the name, telephone number, and address of the funeral home. List the names of family members who were present at the time of death. If they weren't present, note the name of the family member notified and who viewed the body.Jul 22, 2008
Which of the following is part of the medical record?
It includes informationally typically found in paper charts as well as vital signs, diagnoses, medical history, immunization dates, progress notes, lab data, imaging reports and allergies. Other information such as demographics and insurance information may also be contained within these records.Oct 11, 2021
How does HIPAA law regulate the management of electronic medical records?
HIPAA electronic medical records privacy rules allow health care providers to use or disclose patient health information, such as diagnostic images, laboratory tests, diagnoses, and other medical information for treatment purposes without the patient's authorization.
Which of the following are covered by the HIPAA security Rule?
The Security Rule applies to health plans, health care clearinghouses, and to any health care provider who transmits health information in electronic form in connection with a transaction for which the Secretary of HHS has adopted standards under HIPAA (the “covered entities”) and to their business associates.
Why is the identification of patients and patient records so important to release of patient information and patient care quizlet?
It is important because there are laws that protect this information and hefty fines for health organizations that do not follow the laws. Also a patient may not be honest with a physician if he feels his information will not be kept both private and confidential.
What other types of documents may be created in a medical office setting?
The patient registration form, patient medical history, physical examination forms, laboratory results, diagnosis and treatment plans, operative reports, records of follow-up visits and telephone calls, hospital discharge summaries, consent forms, and correspondence with or about the patients are all documents that ...Apr 6, 2018
Which of the following is the primary purpose of a medical record?
The primary purpose of a medical record is to provide a complete and accurate description of the patient's medical history. This includes medical conditions, diagnoses, the care and treatment you provide, and results of such treatments.Feb 2, 2017
Which of the following forms is used to submit health insurance claims for inpatient services?
The CMS-1500 claim form is used to submit non-institutional claims for health care services provided by physicians, other providers and suppliers to Medicare. It is also used for submitting claims to many private payers and Medicaid programs, as well as other government health insurance programs.
What is clinical documentation?
Clinical documentation is not only the means by which the SLP communicates critical information about the patient's diagnosis, treatment, progress, and discharge status to other providers; it also provides the information needed to justify services if the SLP is audited by a payer.
Why is documentation important for speech pathology?
Documentation plays a critical role in communicating to third-party payers the need for evaluation and treatment services (medical necessity) and why those services require the skill of the speech-language pathologist (SLP). Documentation requirements vary by practice setting and by payer.
What does Medicare mean by medical necessity?
Medicare defines medical necessity by exclusion, stating that "…services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury , or to improve the functioning of a malformed body member are not covered ….". (Centers for Medicare & Medicaid Services [CMS], 2014r-a).
Why is documentation important?
Documentation is a critical vehicle for conveying essential clinical information about each patient's diagnosis, treatment, and outcomes and for communication between clinicians and payers. Clinicians must efficiently respond to the questions that payers are asking about each service:
What does it mean when you don't document speech pathology?
State or federal agencies governing health care or licensure for speech-language pathologists may have specific requirements; if those requirements are more string ent, they supersede requirements of facilities, payers, and employment contractors. As the saying goes, "If you didn't document it, you didn't do it.".
What is an evaluation report?
The evaluation report typically is a summary of the evaluation process, any resulting diagnosis, and a plan for service and may include the following elements. reasons for referral;
What are contextual factors?
Contextual factors are personal factors (e.g., age, race, gender, education, lifestyle, and coping skills) and environmental factors (e.g., physical, technological, social, and attitudinal). For examples of functional goals, please see the ICF page on ASHA's website. Components of Clinical Documentation.
What temperature was the patient's fever during his 3 day hospital stay?
The patient had a fever of just above 100 degrees every day during his 3-day admission, including the day of discharge. According to the cardiologist, but not documented in the patient's medical record, the patient declined cardiac catheterization and wanted to be discharged home.
What is the failure to use ordinary care?
Negligence is the failure to use ordinary care, that is, failure to do that which a health care provider of ordinary prudence would or would not have done under the same or similar circumstances. One of the main issues in this case was documentation.
What age did a patient have a myocardial infarction?
A patient had a long-standing history of coronary artery disease, suffering his first myocardial infarction (MI) at age 47. He had recurrent chest pain a year later and underwent a work up to rule out MI. He was treated medically without invasive procedures. Four years after the first MI, he came to a new cardiologist, the defendant in this case.
What is prudent practice?
Prudent practice involves comprehensive documentation. As with the informed consent process, informed refusal should be documented in the medical record. In the case study, the jury found in favor of the plaintiffs when faced with a deceased patient and an undocumented patient decision of great importance.
What is informed refusal?
INFORMED REFUSAL. Texas law recognizes that physicians must obtain consent for treatment and that such consent be "informed.". A variant of informed consent is informed refusal, in which a patient refuses treatment after having been informed of the risks and benefits of the intervention. Many physicians associate the concept ...
How much did the jury award in the case of the syringe?
The jury found the physician negligent and awarded damages of approximately $50,000 for funeral costs, medical expenses, and past mental anguish.
Can refusal to consent to a recommended intervention lead to a lawsuit?
However, as the case study illustrated, a patient's refusal to consent to a recommended intervention can occur under a variety of circumstances, and can lead to lawsuits involving allegations of failure to treat or failure to inform. "Implicit in and intrinsic to the concept of consent for treatment is the option of refusal.
What is medical documentation?
Medical documentation is a document of service that has huge implications for hospital funding. Each issue that is documented is coded and then translated into a cost for the hospital system. Thorough documentation of all medical issues and treatments is therefore crucial for hospital funding. Particularly in discharge summaries.
How to document what a patient tells you about how they are feeling?
It is important to document what the patient tells you about how they are feeling, in their own words. Use quotations if appropriate, using quotation marks. Objective. Here, you should document objective, repeatable and measurable facts about the patient’s status.
What is discharge summary?
The discharge summary is the most comprehensive document surrounding a patient’s admission. It is a crucial form of communication between the medical team and all other individuals who will be involved in the patient’s care. This is largely for the General Practitioner but also allied health and any future medical teams. Keep these audiences clearly in mind when writing a discharge summary. This will help you to draw out the most salient issues of a patient’s admission and to direct a clear plan for other health professionals to follow.
Why is documentation important in healthcare?
Good documentation promotes continuity of care through clear communication between all members involved in patient care. The medical record is a way to communicate treatment plans to other providers regarding your patient. This ultimately ensures the highest quality of patient care.
What is a ward round?
A ward round is the most common activity that a junior medical officer is required to document on a daily basis. You should begin by documenting all the members of the team present. Also, add whether there are any relatives or friends of the patient present to witness the encounter.
Why is clinical documentation important?
First, understanding the critical importance of good documentation is key. There is so much more to documentation than mere legal protection. Medical records are a crucial form of communication. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated.
What to write after a phone conversation?
After the phone conversation, write a note clearly stating who was involved in the conversation, including their role.
What is the number of possible diagnoses and/or the number of management options that must be considered?
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.
What is the key or controlling factor to qualify for a particular level of E/M services?
In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.
What is HPI in medical terms?
The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:
What are the levels of E/M?
The levels of E/M services recognize four types of medical decision making (straight-forward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
What is the primary risk to health care workers and the general population?
The primary risk to health-care workers (HCWs) and the general population is the undiagnosed or unsuspected patient with TB disease. Within health-care settings, protocols should be implemented and enforced to promptly identify, isolate, separate, and either transfer or manage persons who have suspected or confirmed TB disease. Personnel who admit patients to facilities should be trained to detect signs and symptoms of TB disease. People suspected of having TB disease should be given a diagnostic evaluation as soon as possible (see Chapter 4, Diagnosis of Tuberculosis Disease). Clinicians and other HCWs should suspect TB disease in people who have any of the symptoms listed in Table 7.4 and isolate them until TB is excluded.
What is respiratory protection?
Respiratory-protection control is the third level of a TB infection control program and consists of the use of personal protective equipment in situations that pose a high risk for exposure to TB disease (Figure 7.8). Use of respiratory protection can further reduce risk for exposure of HCWs to droplet nuclei expelled into the air. The following measures can be taken to reduce risk for exposure:
What is a TB AII room?
TB AII rooms are designed to prevent the spread of droplet nuclei expelled by a patient with TB disease. In TB clinics, hospitals, and other inpatient settings, patients known to have TB disease or suspected of having TB disease should be placed in a TB AII room immediately. Health-care facilities that provide care for patients with suspected or confirmed TB disease should have at least one AII room. Medical facilities in correctional settings should also have at least one AII room. The need for additional AII rooms should be based on the TB risk assessment for the setting.
What is mechanical ventilation?
Mechanical ventilation refers to the use of equipment to circulate and move air in a building. Mechanical ventilation should be used by hospitals, TB clinics, and other health-care and congregate settings expecting to see a confirmed or suspected TB patient. Mechanical ventilation consists of
How does natural ventilation work?
Natural ventilation relies on cross ventilation in a building designed for good air exchange; for example, the use of open doors and windows to bring in air from outside. Natural ventilation can be useful for nontraditional facility-based and congregate settings that do not have a central ventilation system. In these settings, waiting rooms, shelter dormitories, or other rooms in which people congregate should have an operable window, door, or skylight that is kept open as often as possible. Fans can be used to help distribute the air (Figure 7.1). If the direction of airflow is unknown, staff should sit near the fresh air source and clients should sit near the exhaust location (Figure 7.2). This can help protect staff from droplet nuclei expelled by patients with unidentified TB disease. In addition to these environmental measures, cough etiquette and respiratory hygiene should be encouraged to further reduce risk (Figure 7.3).
What are primary environmental controls?
Primary environmental controls consist of controlling the source of infection by using local exhaust ventilation (e.g., hoods, tents, or booths) and diluting and remo ving contaminated air by using general ventilation.
What is the purpose of risk classification?
The purpose of the risk classification is to determine the need for a TB testing program for HCWs and the frequency of testing. The risk classification, or risk level, will vary; however, all settings should perform risk classification as part of risk assessment to determine the need for and frequency of a HCW testing program, regardless of the likelihood of encountering persons with TB disease. Baseline TB testing should be conducted for HCWs upon hiring (see Chapter 3, Testing for Tuberculosis Infection and Disease). The three TB risk classifications are indicated in Table 7.5.
What are the four drugs that are included in the initial treatment regimen?
Four drugs— INH, RIF, PZA, and EMB — should be included in the initial treatment regimen until the results of drug-susceptibility tests are available. Each of the drugs in the initial regimen plays an important role. INH and RIF allow for short-course regimens with high cure rates. PZA has potent sterilizing activity, which allows further shortening of the regimen from 9 to 6 months. EMB helps to prevent the emergence of RIF resistance when primary INH resistance is present. If drug-susceptibility test results are known and the organisms are fully susceptible, EMB need not be included. For children whose clarity or sharpness of vision cannot be monitored, EMB is usually not recommended except when the risk of drug resistance is high or for children who have “adult-type” (upper lobe infiltration, cavity formation) TB disease.
Why is it important for clinicians to evaluate a patient's response to treatment?
It is important for clinicians to evaluate a patient’s response to treatment to determine the ecacy of the treatment and to identify any adverse reactions. Clinicians use three methods to determine whether a patient is responding to treatment:
How long does it take to treat TB?
As a general rule, the principles used for the treatment of pulmonary TB disease also apply to extrapulmonary forms of the disease. A 6-month treatment regimen is recommended for patients with extrapulmonary TB disease, unless the organisms are known or strongly suspected to be resistant to the first-line drugs. If PZA cannot be used in the initial phase, the continuation phase must be increased to 7 months. The exception to these recommendations is central nervous system TB, for which the optimal length of therapy has not been established but some experts recommend 9 to 12 months. Most experts do recommend corticosteroids to be used as additional therapy for patients with TB meningitis and pericarditis. Consultation with a TB expert is recommended.
How long is the TB continuation phase?
The continuation phase of treatment is given for either 4 or 7 months. The 4-month continuation phase should be used in patients with uncomplicated, noncavitary, drug-susceptible TB, if there is documented sputum conversion within the first 2 months. The 7-month continuation phase is recommended only for
What is the recommended treatment regimen based on?
The recommended treatment regimens are based, in large part, on evidence from clinical trials and are rated on the basis of a system developed by the U.S. Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) (Table 6.3).
How to educate patients about TB?
Educating patients about TB disease helps ensure their successful completion of therapy. Health-care providers must take the time to explain clearly to patients what medication should be taken, how much, how often, and when. Patients should be clearly informed about possible adverse reactions to the medications they are taking and when to seek necessary medical attention. Providing patients with the knowledge they need regarding the consequences of not taking their medicine correctly is very important. In addition, patients should be educated about infection control measures and potential need for isolation (Table 6.1). HIV testing and counseling is recommended for all patients with TB disease in all health-care settings. The patient must first be notified that testing will be performed. The patient has the right to decline HIV testing and counseling (opt-out screening).
What are the drugs that treat TB?
Food and Drug Administration (FDA) for the treatment of TB disease (Table 6.2). In addition, the fluoroquinolones (levofloxacin, moxifloxacin, and gatifloxacin), although not approved by the FDA for TB disease, are commonly used to treat TB disease caused by drug-resistant organisms or for patients who are intolerant of some first-line drugs. Rifabutin, approved for use in preventing Mycobacterium avium complex disease in patients with HIV infection but not approved for TB disease, is useful for treating TB disease in patients concurrently taking drugs that interact with rifampin (e.g., certain antiretroviral drugs). Amikacin and kanamycin, nearly identical aminoglycoside drugs used in treating patients with TB disease caused by drug-resistant organisms, are not approved by the FDA for treatment of TB.
Case Study
Informed Refusal
The Process of Informed Refusal
Assessing Decision-Making Capacity
Documenting Informed Refusal
Other Risk Management Considerations
- In addition to documenting the informed refusal discussion, the following recommendations may help minimize the risk of lawsuits related to patient refusals. 1. As part of routine care, inquire about and encourage patients to complete advance directives before serious illness or capacity questions arise. "If the patient has an Advance Directive or ...
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