Chapter 18Legal Reporting RequirementsLearning Objective
- 1. Chapter 18 Legal Reporting Requirements Learning Objectives Describe various forms of child abuse, how to recognize it, and reporting requirements. Describe various forms of elder abuse, how to recognize it, and reporting requirements. Explain why it is important to report communicable diseases, adverse drug reactions, & infectious diseases. Learning Objectives (cont’d) Discuss the importance of reporting births and deaths. Explain how & why physician incompetency is reported. Understand the importance of incident reporting, sentinel events, & the purpose of root cause analyses. Abuse Abuse in the healthcare setting often occurs to those who are most vulnerable and dependent on others for care. Abuse can take many forms, such as physical, psychological, medical, and financial. Abuse is not always easy to identify because injuries can often be attributed to other causes.
- 2. Child Abuse Intentional serious mental, emotional, sexual, &/or physical injury inflicted by family or other person responsible for care. Child Abuse Prevention & Treatment Act (CAPTA) Minimum standards states must incorporate in their statutory definitions of child abuse and neglect. Child Abuse Who Should Report Healthcare setting Administrators, physicians, interns, registered nurses, chiropractors, social service workers, psychologists, dentists, osteopaths, optometrists, podiatrists, mental health professionals, & volunteers in residential facilities Penalties for failure to report States vary on penalties Child Abuse How to Detect Indicators of abuse and maltreatment that appear to be part of a pattern Physical indicators Bruises Sprains Fractures Cigarette burns
- 3. Child Abuse How to Detect (cont’d) Behavioral indicators Diminished psychological or intellectual functioning Failure to thrive No control of aggression Self-destructive impulses Decreased ability to think and reason Acting out and misbehavior, or habitual truancy Child Abuse (cont’d) Good faith reporting Psychologist Immune to Liability Failure to report child abuse Psychologist’s Failure to Report Abuse Nurse’s Failure to Document and Report Physician Entitled to Immunity Child Abuse Can Be Elusive Senior Abuse Mistreatment: Results in Harm or Loss It can involve Physical & Sexual Abuse Domestic & Psychological Abuse Financial abuse Neglect Failure to provide needed care
- 4. Senate Select Committee on Aging Less Likely to be Reported than Child Abuse Most Instances of Senior Abuse Repeated Events Not One-Time Occurrences Senate Select Committee on Aging (cont’d) Victims are often 75 years of age or older, & women more likely to be abused than men. Seniors often ashamed to admit their loved ones abuse them. may fear reprisals if they complain. Family members are resentful of a frail & dependent senior parent. Majority of abusers are relatives. Signs of Senior Abuse Unexplained or Unexpected Death Development of “Pressure Sores” Heavy Medication & Sedation Inadequate nursing staff Occurrence of Broken bones Sudden Emotional Outbursts/Agitation/Withdrawal Signs of Senior Abuse (cont’d) Bruises, welts, discoloration, and burns Absence of hair Hemorrhaging below the scalp
- 5. Dehydration and malnourishment without illness- related cause Hesitation to talk openly Implausible stories Signs of Senior Abuse (cont’d) Unusual or inappropriate activity in bank accounts. Signatures on checks and other written materials that do not resemble patient’s signature. Power of attorney given, or recent changes or creation of a will, when person is incapable of making such decisions. Signs of Senior Abuse (cont’d) Missing personal belongings, such as silverware or jewelry. An untreated medical condition. Patient unable to speak for himself or herself, or see others, without presence of caregiver (suspected abuser). National Center on Elder Abuse The National Center on Elder Abuse (NCEA), directed by the U.S. Administration on Aging, is committed to helping national, state, and local partners in the field be fully prepared to ensure that older Americans will live with dignity, integrity, independence, and without abuse, neglect, and exploitation. Preventing Abuse Policies and Procedures Prohibition of Mistreatment
- 6. Description of Reporting Procedures Regarding Alleged Abuse Maintenance of Evidence of Alleged Abuse Investigation of Alleged Abuse Prevention of further potential abuse while investigation is in progress Abuse Documentation Suspected abuse should be defined clearly and objectively. Witnesses: Reporters of abuse must describe statements made by others as accurately as possible. What actions were taken, by whom, when, where, etc. Information should be included about how witnesses may be contacted. Abuse Documentation (cont’d) Photographs: It may be necessary to photograph wounds or injuries. Hospital emergency room or the police department can be asked to photograph in emergency situations. Communicable Diseases Reported to Protect citizens from Infectious Diseases Reporting Required by Statutes AIDS State HIV Required Reporting
- 7. Mandatory Testing Births and Deaths Reportable by Statute Necessary to Maintain Accurate Census Medical Examiner Suspicious Deaths Determines Cause of Death Adverse Drug Reactions Harmful Drug Reactions Result of Administration of a Drug or Combination of Drugs MedWatch FDA Program for Reporting Harmful Reactions Physician Competency Health Care Quality Improvement Act Authorizes National Practitioner Data Bank to collect & release information on professional competence & conduct of health care practitioners. National Practitioner Data Bank Created by Congress as national repository of information with primary purpose of facilitating a comprehensive review of healthcare practitioners’ professional credentials Operates Under Authority of the Secretary of DHHS Established to protect public by restricting ability of unethical
- 8. or incompetent practitioners from moving state to state without disclosure or discovery of previously damaging or incompetent performance National Data Bank Reporting Reporting Requirements Required Queries Required Reporting Data bank Queries Query Fees Penalties for Failing to Report Confidentiality of Data Bank Information Incident Reporting States Reportable Incidents Serious Injury or Death Hospital Acquired Infections Fires Loss of Power Employment Strikes Incident Reporting, cont’d The Deficit Reduction Act, amended in 2008, cites hospital - acquired infections Medicaid and Medicare will not reimburse hospitals for. Catheter-associated urinary tract infections Surgical site infections following bariatric surgery Surgical site infections following certain elective surgery, &
- 9. surgical site infections Incident Reporting Incident/Occurrence Reports Discoverable. Incident Reports Should Not be Placed in the Medical Record Sentinel Events Unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. “Or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Unanticipated Death Major Permanent Loss of Function Sentinel Events (cont’d) Suicide Unanticipated death of a full-term infant Infant abduction Rape Hemolytic transfusion reaction Surgery on the wrong patient or wrong body part Root Cause Analysis
- 10. Process for identifying basic or causal factors that underlie the variation in performance including the occurrence or possible occurrence of a sentinel event. Root Cause Analysis, cont’d Thorough Credible Investigation involves general and special causes Researching Literature Search for Best Practices Implementing & Monitoring Change Review Questions Describe various forms of child abuse, how to recognize it, & reporting requirements. Describe various forms of elder abuse, how to recognize it, & reporting requirements. Discuss importance of reporting births & deaths. Review Questions (cont’d) Explain why it is important to report communicable diseases, adverse drug reactions, & infectious diseases. Explain how & why physician incompetency is reported. Explain the importance of incident reporting, sentinel events, & the purpose of root cause analyses.
- 12. 12345678910111213141516171819202122232425262728293031 32 Chapter 13 Information Management & Patient Records Learning Objectives Describe the contents of medical records.
- 13. Explain the importance of maintaining complete and accurate records. Explain the ownership of and who can access a patient’s medical record. Describe the advantages and disadvantages of electronic medical records. Learning Objectives, cont’d Describe why the medical record is important in legal proceedings. Describe a variety of ways in which medical records have been falsified. Explain what is meant by the medical record battleground. Information Management Determine Customer Needs Set Goals & Establish Priorities Improve accuracy of data collection Provide Uniformity in Data Collection Definitions Limit Duplication of Entries Information Management, cont’d Deliver Timely & Accurate Information Provide Easy Access to Information Maintain Security & Confidentiality of Information Enhance Patient Care Activities Improve Collaboration through Information Sharing Information Management, cont’d
- 14. Establish Disaster Plans for Information Recovery Provide Orientation & Staff Training Annual Review of Information Management Plan Scope Organization Objectives effectiveness Medical Record Means of Communication Documentation of Patient’s Illness Symptoms Diagnosis Treatment Medical Record Means of Communication, cont’d Communication Tool (e.g., progress notes) Protect Legal Interests of Patient & Provider Provide Database for Use in Statistical Reporting Continuing Education Research Provide Information for Billing Medical Record Contents Admission record
- 15. Age Address Reason for admission Social security number Marital status Religion Health insurance Medical Record Contents, cont’d Consent Authorization for Treatment Advance Directives History & Physical Exam Diagnosis Information that Supports the Diagnosis Patient Screenings & Assessments Medical Record Contents, cont’d Treatment plan Physicians‘Orders Progress Notes Nursing Notes * Integrated record includes physician progress & nursing notes along with the notes of other disciplines Medical Record Contents, cont’d Diagnostic Reports e.g., EKG, EEG, laboratory & imaging Consultation Reports Vital Signs Fluid Intake & Output
- 16. Pain Management Records Anesthesia Assessment Medical Record Contents, cont’d Operative reports Medication Administration Records Discharge Planning Patient education Discharge summaries Documentation of Care Record Accurate Entries Nurse’s Charting Documentation & Reimbursement Charting by Exception Failure to Maintain Records Medical Record Battleground Privacy Act of 1974 5 U.S.C. 552 Enacted to safeguard individual privacy from misuse of federal records, to give individuals access to records concerning themselves that are maintained by federal agencies, & to establish a Privacy Protection Safety Commission. Health Insurance Portability & Accountability Act (HIPAA) Designed to protect the privacy, confidentiality, & security of patient information. Standards apply to all health information in all formats.
- 17. HIPAA Privacy Provision Patients are able to access their records & request correction of errors. Patients must be informed of how personal information will be used. Patient consent for release of information for marketing purposes required. Patients can ask insurers & providers to take reasonabl e steps to ensure their communications are confidential. Patients can file privacy-related complaints. HIPAA Privacy Provision, cont’d Health insurers or providers document their privacy procedures. Health insurers or providers designate a privacy officer and train their employees. Providers may use patient information without patient consent for Purposes of providing treatment Obtaining payment for services Performing non-treatment operational tasks of the provider’s business HIPAA Security Provision Policies and procedures are designed to show how the entity will comply with the act. Entities must adopt a written set of privacy policies & procedures.
- 18. The privacy officer develops and implements policies and procedures. Policies and procedures must reference management oversight & organization buy-in to comply with documented security controls. Procedures identify employees who will have access to protected health information. Access to protected health information (PHI) in all forms is restricted to employees who have a need for it to complete job function. HIPAA Security Provision, cont’d Procedures address access authorization, establishment, modification, & termination. There is an ongoing training program. Entities that outsource business processes to a third party ensure vendors have framework to comply with HIPAA. Care is taken to determine if the vendor further outsources any data handling functions to other vendors, while monitoring whether appropriate contracts & controls are in place. There is a contingency plan for responding to emergencies. Covered entities are responsible for backing up their data & having disaster recovery procedures in place. HIPAA Security Provision, cont’d Recovery plan should document data priority & failure analysis, testing activities, and change control procedures. Internal audits review operations with goal of identifying potential security violations. Policies & procedures document scope, frequency, & procedures of audits. Audits are routine & event based.
- 19. Procedures document instructions for addressing & responding to security breaches. HIPAA Physical Safeguards Responsibility for security must be assigned to a specific person or department. Controls must govern the introduction & removal of hardware and software from the network. When equipment is retired, it must be disposed of properly to ensure that PHI is not compromised. Access to equipment containing health information should be carefully controlled and monitored. Access to hardware & software must be limited to properly authorized individuals. HIPAA Physical Safeguards, cont’d Required access controls consist of facility security plans, maintenance records, & visitor sign-in and escorts. Policies are required to address proper workstation use. Workstations should be removed from high-traffic areas & monitor screens should not be in direct view of the public. If the covered entities utilize contractors or agents, they too must be fully trained on their physical access responsibilities. HIPAA Technical Safeguards Information systems housing PHI must be protected from
- 20. intrusion. When information flows over open networks, some form of encryption must be utilized. If closed systems/networks are utilized, existing access controls are considered sufficient and encryption is optional. Each covered entity is responsible for ensuring data within its systems has not been changed or erased in an unauthorized manner. HIPAA Technical Safeguards, cont’d Data corroboration, including use of check sum, double-keying, message authentication, & digital signature may be used to ensure data integrity. Covered entities must also authenticate entities with which they communicate. Authentication consists of corroborating that an entity is who it claims to be. Covered entities must make documentation of their HIPAA practices available to the government to determine compliance. HIPAA Technical Safeguards, cont’d Information technology documentation should also include a written record of all configuration settings on components of the network because these components are complex, configurable, & always changing. Documented risk analysis & risk management programs are required.
- 21. HITECH Act Provides Secretary of HHS must post a listing of breaches of unsecured protected health information affecting 500 or more individuals Medical Records Ownership and Release News: Hospital Workers Punished for Peeking at Clooney File Ownership resides with the organization or professional rendering treatment. Right to Privacy Medical Records Ownership and Release, cont’d Request by patients Failure to release records Legal action Requests: Third parties Insurance carriers processing claims Medical researchers Educators Government agencies Privacy exceptions Criminal investigations Medicaid fraud Substance abuse records Use Of Patient Data Gathered Provider mistakes often occur because of unwieldy,
- 22. unorganized, & voluminous amounts of information gathered on patients. Caregivers who fail to use information collected when assessing patient needs may & themselves in a lawsuit. Todd v. Sauls Physician breached his duty of care for Failure to Read Nursing Notes Retention of Records Varies State to State. Failure to Preserve X-rays Illinois Supreme Court held hospitals must retain X-rays & other such photographs or films as part of their regularly maintained records for a period of 5 years. Rodgers v. St. Mary's Hosp. of Decatur Electronic Medical Records Advantages Retrieves patient information Improves productivity and quality Reduces costs Supports clinical research Education Computer-assisted diagnosis & treatment Electronic Medical Records Advantages, cont’d Allows for computer-generated prescriptions Generates reminders for follow-up testing Assists in decision-making process Aids in standardizing treatment protocols
- 23. Assists in identification of drug-drug & food-drug interactions Telecommunications Electronic Medical Records Disadvantages Increased risk of lost confidentiality & unauthorized disclosure of information Technology crime & related illegal activities Increase in cyber crime Costs to protect networks & critical infrastructures from cyber - based threats One checkmark on a computer form can populate many fields & multiple pages giving the impression that a thorough patient assessment was conducted. Legal Proceedings & the Medical Record Complete, Accurate, & Timely Records Reconstructs Events Surrounding Alleged Negligence Aid Police in Investigations Provides Information as to the Cause of Death Aids in Information Recall for Witnesses Falsification of Medical Records Falsifying Medical Records Alteration & Destruction of Medical Records Tampering with Medical Records Falsifying Business Records Nurse Changes Record Entries
- 24. Falsification of Medical Records, cont’d Alteration of Records News: Falsified Patient Records Are Untold Story Of California Nursing Home Care Failure to Record Patient’s Condition Illegible Handwriting Poor penmanship can lead to patient injury. The American Medical Association encourages physicians to print, type, or computerize their orders. A Harvard study found that penmanship was among the causes of 220 prescription errors out of 30,000 cases. Timely Completion Medical Records Caregivers must promptly complete records. Failure to timely record patient information can lead to forgetfulness and documenting the wrong information on the wrong record. Failure to complete records as required by policy can be the basis for suspension of privileges. Confidential & Privileged Communications Attorney-client privilege Physician-patient confidentiality HIV Confidentiality Disclosure of Physician’s HIV Status Disclosure of Physician’s HIV Status HIV Status “Improperly” Disclosed to Employer
- 25. Confidential & Privileged Communications, cont’d. HIV Status “Properly” Disclosed to Employer News Media Reports of the Joint Commission Privileged from Discovery Privileged Information: Statements Protected Credentialing Files Privileged Ordinary Business Documents Confidential and Privileged Communications, cont’d Committee minutes discoverable Peer review documents privileged Peer review documents not privileged Staff privileging documents discoverable Case: Illinois Staff credentialing documents not discoverable Case: South Carolina Charting Helpful Advice Complete and pertinent entries Timely entries Legible entries Clear and meaningful entries Complete
- 26. Charting Helpful Advice, cont’d Avoid Defensive and derogatory notes Erasures and correction fluids Criticism Complaints Tampering with the chart Secure records pending legal action Charting Helpful Advice, cont’d Obtain legal advice Entries made by others must not be ignored Patient care is a collaborative interdisciplinary team effort Entries made by healthcare professionals provide valuable information in treating the patient Charting Helpful Advice, cont’d Reasoning for not following the advice of a consultant should be noted in the medical record, not so as to discredit the consultant, but to show the reasoning why a consultant’s advice was not followed. Review Questions Describe the importance of information management
- 27. planning. Describe the importance & contents of medical records. Explain the importance of maintaining complete & accurate records. Review Questions, cont’d Discuss how the Privacy Act of 1974 & the HIPAA of 1996 safeguard a patient’s privacy. Explain the ownership of & who can access a patient’s medical record. Describe the advantages & disadvantages of electronic medical records. Review Questions, cont’d Describe why the medical record is important in legal proceedings. Describe a variety of ways in which medical records have been falsified. Explain what is meant by the medical record battleground.