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acts consist of professional misconduct, improper discharge of professional duties, and failure to meet professional standards of care that result in harm to another person

Vital Statistics

birth and death dates, are used by the government, public health agencies, and other institutions to determine population trends and needs

Information needed on a Death Certificate

date, time, cause (diseases, injuries, or complications) how long the they were treated for before death, presence or absence of pregnancy, if an autopsy took place

What happens if you do not report child abuse

may result in a charge of misdemeanor

Who signs the Birth Certificate

physician or mid-wife

What is a Communicable Disease

transmitted from one person to another and are considered a general threat to the public, example is chickenpox

Signs of Abuse

repeated injuries, bruises, unexplained fractures, bite marks, unusual marks, cigarette burn, swelling or pain in genital area, inadequate nutrition, sunken eyes and weight loss, venereal disease and genital abrasions and infections, sunglasses to hide black eyes

Evidence that you would gather in an abuse case

photo of bruises or other signs, sperm inside a female, clothing, body fluids, various samples, foreign objects like bullets, hair, and nail clippings

FDA Food and Drug Administration

ultimately enforces prescription drugs and over-the-counter sales and distribution

DEA Drug Enforcement Administration

controls drugs that have a potential for addiction, habituation, or abuse that are regulated, known as the Controlled substances Act of 1970, the act regulates the manufacture and distribution of the drugs into five categories that are called Schedules 1-5

EAP Employment Assistance Program

management-financed and confidential counseling and referral service, it is designed to help employees or their family with alcoholism or marital strife

Schedule I

highest potential for addiction and abuse, can not be used for medical use, maybe used for research purposes only, ex marijuana, heroin, and LSD - Can not be prescribed

Schedule II

highest potential for addiction and abuse, accepted for medical use, ex codeine, cocaine, morphine, opium, and secobarbital - The DEA licensed physician must complete triplicate prescription forms in their handwriting, must be filled within seven days, must be stored under lock and key if in office premises, dispensing record must be kept for two years

Schedule III

moderate to low potential for addiction and abuse, ex butabarbital, anabolic steroids, and APC with codeine - DEA number is not required to prescribe these drugs, physician must handwrite the order, five refills allowed per 6 months, only the physician can telephone the pharmacist for these drugs

Medical Records

contain both personal information about the patient and medical or clinical notations supplies by the physician and other healthcare professionals caring for the patient

Personal Patient Information

includes full name, address, telephone number, date of birth, marital status, employer, and insurance information

Clinical Data

all records of medical examinations, including x-rays, laboratory reports, and consent forms

7 requirements that a Medical Record must include

admitting diagnosis, evidence of a physician examination, including a health history, not more that seven days before admission or 48 hours after admission to a hospital, documentation of any complications such as hospital-acquired infections or medical reactions, signed consent forms for all treatments, consultation report from any other physician brought into case, all physicians "notes, nurses' notes, treatment reports, medication records, radiology and laboratory reports, anything used to monitor the patient, discharge summary, with follow-up care noted

What is the exception for medical records to be excepted from State Medical Law

if the patient should require emergency care that would necessitate divulging the abuse problem

What happens if you have incomplete Medical Records in court

If its not in the chart, it didn't happen

How long should you store all Medical Records

10 years from last entire

How long do you have to file a claim after you are discharged

30 days

Compensatory Damages

payment for the actual loss of income, emotional pain and suffering, or injury suffered by the patient

Punitive Damages

also called exemplary damages, are monetary awards by court to a person who has been harmed in an especially malicious or willful way

Nominal Damages

refer to a slight or token payment to a patient to demonstrate that, while there may not have been any physical harm done, the patients legal rights were violated

Assumption of Risk

the legal defense that prevents a plaintiff from recovering damages if the plaintiff voluntarily accepts a risk associated with the activity

Contributory Negligence

refers to conduct on the part of the plaintiff that is a contributing cause of an injury, the patient may be barred from recovering monetary damages, spending on how the state allocates damages

Comparative Negligence

the plaintiff's own negligence helped cause the injury

What doctrine means "the thing speaks for itself"

res ipsa loquitur


refers to performing a wrong and illegal act, ex for a MA to prescribe medical treatment or prescriptions


is the improper performance of an otherwise proper or lawful act, ex when a poor technique is used by a nurse to draw blood and the patient stuffers nerve damage


the failure to perform a necessary action, ex not giving CPR to a patient collapsing in the waiting room when you are a nurse on duty

DEA Number

first Letter stands, "A" would be the physician or "M" for the mid-wife. second Letter stands for the initial of the physician's Last Name. 9 letters and numbers and only the first two are letters

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