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Chapter 9 Law & Ethics
Terms in this set (30)
How long should a medical record be kept for one-year-old child who resides in a state with a statute of limitations of two years for a tort offense?
The medical record should be kept until the age of maturity plus the two years. If the age of maturity is 18, then it would be until the age of 20, if the maturity age is 21, then it would be kept until the age of 23.
What does a subpoena duces tecum request request the subpoenaed person to provide?
To appear in court, give testimony, and bring the particular records, files, books or information that is described in the subpoena.
Exactly what does "timeliness in documentation" mean?
That all entries should be made as they occur or as soon as possible afterward.
What are some of the precautions to follow when using electronic medical records?
Key in all information correctly. Make sure a firewall is on the computer. Make sure a password is on the computer to lock it.
What would you say to a patient who demands his x-ray and says "It's my x-ray. I paid for it?"
I understand, I be glad to give you a copy, but the original x-ray belongs to the doctor.
What is the doctrine of professional discretion?
a physician may determine based on his or her judgment if the patient with mental or emotional problems should view the medical record
What are some examples of a "custodian of the record?"
Who can serve a subpoena?
Sheriff (Deputy), State Attorney Investigators, Florida Department of Law Enforcement Special Agents, Duly Appointed and Bonded Process Servers.
Explain the precautions that must be taken when faxing medical records.
1. Send patient information via fax only when absolutely necessary
2. Verify the fax telephone number of the receiver before sending the fax
3. Make sure the intended receiver is there before sending confidential records by fax.
4. Shred confidential fax papers that are no longer needed. Do not place them in the trash
5. Use a fax cover sheet that states "Confidential. Please return if received error."
6. Only fax the specific documents requested, not the entire medical record
7. Do not leave confidential material unattended on fax machine.
8. Ideally, the fax machine should be located in restricted access area.
Explain the precautions that must be taken when using a computer in a medical setting.
1. Avoid using email to send confidential information
2. do not allow other patients or unauthorized staff members to view a computer screen with confidential patient information.
3. Screen savers should e used to prevent confidential patient information being viewed by others.
4. Computer screens should be out of view of the general public
5. Passwords should be changed on a regular basis and not shared with others. ( every 30-60 days)
when something has been requested by the court
in the order of occurrence
falsification of records
grounds for criminal indictment
subpoena duces tecum
written order to bring materials to court
electronic medical record
no late entries on medical chart
scrambling & encoding information
Joint Commission on Accreditation of Healthcare Organizations
Medicare and Medicaid records should be retained for
The contents of the medical records include all of the following except
patient's income level
Medical record entries should be made
as soon as possible
has the legal right of privileged communication
When correcting a written medical error, one should
draw a line through the error, write the correction above
The medical records is legally owned by the
provide a record from birth to death, provide statistics on health matters, are legal documents
All of the following are guidelines to use when sending medical records by fax except
send the entire medical record via fax
An exception to the open-records laws in some states is/are
safety and criminal records of persons involved in the education of children
The records of all adult patients should be kept a minimum of
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