“Information Management and Allied Professional Issues” Please respond to the following: •* From the scenario, analyze the primary problems associated with information management, and analyze the primary issues associated with patient confidentiality. De
this is a discussion not a PAPER. A paragraph under each topic 250 words each paragraph
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HSA 515, Lecture 6, Allied Health Professionals and Information Management |
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Slide # |
Scene/Interaction |
Narration |
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Slide 1 |
Scene 1 Professor Charles enters classroom and introduces the topics for today’s lesson and begins the lecture. |
Prof Charles: Hello everyone. Today, although there are a variety of legal issues, we are going to discuss an overview of selected health care organization departments or professions and information management systems capable of collecting and sharing essential patient health information.
Healthcare professionals are never exempt from the long arm of the legal system. Healthcare professionals are held to the prevailing standard of care required in their profession, which includes proper assessments, reassessments, diagnosis, treatment, and follow-up care.
Dental malpractice cases are usually related to patients who suffer from complications of a dental procedure. They can involve the improper treatment of dental infections or complications from the improper administration of anesthesia. Complications can also include damage to the nerves of the lower jaw, face, lips, and tongue. Injuries to sensations in the tongue can result from high-speed drills.
To significantly reduce the tens of thousands of deaths and injuries caused by medical errors every year, healthcare organizations must adopt information management systems that are capable of collecting and sharing all health information on patients and their health care.
Let’s first discuss emergency departments which are high-risk areas for hospitals. What are the objectives of emergency care regardless of severity?
Casey: The treatment must be as fast as possible so function is maintained or restored, scarring and deformity are minimized, and so forth.
Casey: In addition, the hospital emergency department has a duty to not only treat but admit patients on a timely basis.
Prof. Charles: Absolutely. What are some of the other potential liabilities of the hospital emergency department?
Casey: The Emergency Medical Treatment and Active Labor Act (EMTALA) forbids Medicare-participating hospitals from dumping any patient out of emergency departments. The patient who is presented to the emergency department should receive appropriate medical screening and treatment within the capability of the hospital emergency department. Patients who need specialized care not available in the department or hospital must be medically stabilized before being transferred to another hospital. The patient transfer must be medically appropriate.
Prof. Charles: What is another example of such liability?
Donald: There was a case in which a patient was admitted to the hospital emergency department after an automobile accident. The parents of the patient arrived and learned from the attending physician that the patient was okay to go home and get some rest. The physician had looked at the medical chart of another patient and missed the broken ribs, internal hemorrhaging, and falling blood pressure.
The parents took the son home and in a few hours developed a swollen abdomen and continued severe pain. The patient died at home and was pronounced dead later at the hospital. The court ruled that the attending physician’s review of the wrong record was a fatal mistake and resulted in a wrongful death.
Prof. Charles: Great job Donald! Now let’s take a closer look at preventing lawsuits and injuries in the emergency department. Lawsuits can be reduced by: Treating patients courteously and promptly; Treating all patients regardless of ability to pay; Triaging and treating seriously ill patients first; Communicating with the family and the patient to gain an accurate picture of the patient’s medical condition; Requiring consultations when determined necessary; and Making appropriate arrangements and communication, when required, for transfer. |
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Slide 2 |
Check Your Understanding Which of the following is not the duty of the hospital emergency department? A. Patient presents to the hospital emergency department with a gunshot wound after robbing a bank. B. Patient leaves hospital emergency department against doctor’s orders and subsequently dies. C. Physician will not treat seriously injured non-paying emergency department patient Correct Feedback: B. Patient leaves hospital emergency department against doctor’s orders and subsequently dies.
Incorrect Feedback: A. Patient presents to the hospital emergency department with a gunshot wound after robbing a bank.
C. Physician will not treat seriously injured non-paying emergency department patient
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Slide 3 |
Scene 2 Discussion between Prof Charles and students. |
Prof. Charles: Patients can be transferred only after they have been medically screened by a physician, stabilized, and cleared for transfer by the screening institution. Stabilized means “with respect to an emergency condition…to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.” A patient cannot be transferred unless the medical treatment available at another facility can reasonably be expected to outweigh the increased risk to the patient staying at the same hospital.
Physicians who do not want to comply with the transfer requirements of the Emergency Medical Treatment & Labor Act should only affiliate with hospitals that do not accept Medicare funds or do not have an emergency department.
The public not only relies on medical care provided by emergency departments, but also considers the hospital as a single entity providing all of its medical services.
Legislation in many states imposes a duty on hospitals to provide emergency care. If the public knows a hospital provides emergency care and relies on that knowledge, the hospital has a duty to provide those services to the public.
Healthcare organizations are expected to provide patients with pharmacy services. Doctors and nurses find it almost impossible to keep up with the information required for safe medication use. The pharmacist has become an essential resource in modern hospital practice.
Among the non-operative adverse events, medication errors are considered a leading cause of medical injury in the United States. Antibiotics, chemotherapeutic drugs, and anticoagulants are the three categories of drugs responsible for many drug-related adverse events. The activity of preparing, compounding, and retailing medications is controlled by the pharmacy and governed by state law. Pharmacists are required to be licensed by the state. The hospital patient’s drug regimens must be reviewed by the hospital pharmacist.
Casey: So, Professor Charles, can you tell us more about licensing health care professionals?
Prof. Charles: Absolutely! Licensure can be defined as the process by which some competent authority grants permission to a qualified individual or entity to perform certain specified activities that would be illegal without a license. The commonly stated objectives of licensing laws are to limit and control admissions to the different healthcare occupations and to protect the public from unqualified practitioners by promulgating and enforcing standards of practice within the professions.
Donald (interrupts): Just to be clear, the certification of healthcare professionals is the recognition by a government or professional association that an individual’s expertise meets the standards of that group. Some professional groups establish their own minimum standards for certification in those professions that are not licensed by a particular state. Certification by an association or group is a self-regulation credentialing process.
Prof. Charles: Yes, but licensing boards have the authority to suspend or revoke the license of healthcare professionals found to have violated specific norms of conduct. Groups or associations which self-regulate credentialing can revoke or suspend certification of a healthcare professional.
Casey: I am still not quite clear on the multidisciplinary approach to patient care. Can you elaborate on it some more
Prof. Charles: Sure….Do patients believe that care is always well coordinated? Do pharmacists find it necessary to contact the doctor when there are questions regarding dosage? Would it be helpful for the prescribing physician to discuss his patient’s needs with the treating therapist?
Regardless of the profession or healthcare setting, a multi-disciplinary approach to patient care is a must in any organization. Healthcare professionals need to consider and discuss what questions they might ask if they were a patient undergoing treatment.
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Slide 4 |
Check Your Understanding To significantly reduce the tens of thousands of deaths and injuries caused by medication errors every year, health care organizations must adopt ____________ that are capable of collecting and sharing essential health information on patients and their care A. Information systems B. Hand written notes Correct Feedback:
Incorrect Feedback: B. Hand written notes is incorrect. Hand written notes can be misread and often not readily available for caregivers resulting in injuries to the patient by misdiagnosis, errors in drug administering, and delayed treatment.
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Slide 5 |
Check Your Understanding A Healthcare records are the property of the_____________ and are maintained for the benefit of the patient.
B. Provider of care. C. Federal government. D. Licensing agency Correct Feedback: B. Provider of care is the correct answer. Patients have a right to access their records and obtain copies. Failure to release records can lead to legal action by the patient. Incorrect Feedback: A. Incorrect. State C. Incorrect. Please try again. D. Incorrect. Please try again. Remember. Ownership resides with the organization rendering treatment. |
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Slide 6 |
Scene 3 Discussion of information management and the law |
Prof. Charles: Now let’s discuss information management and the law.
Can anyone explain the rights of patients and their medical record?
Casey: I think I can. Patients may have access to review and obtain copies of their records. Access to information includes records maintained or possessed by a healthcare organization or healthcare provider such as a physician’s office, who has treated or is treating a patient. Organizations and physicians can withhold records if the information could reasonably be expected to cause harm to the patient. For example, patients in psychiatric hospitals, institutions for the mentally disabled, or alcohol and drug treatment programs.
Prof. Charles: Very good Casey! That is an excellent explanation.
Donald: Prof. Charles, what about the retention of medical records?
Prof. Charles: Donald that is a great question. The length of time medical records must be retained varies by state. One state may require the medical record be retained for five years and another for seven years. Healthcare organizations must take into consideration such things as state law; Needs of its patients; Future needs for such records; and Legal considerations of having the record available in the event of a lawsuit.
Casey: Do computers help in retaining medical records?
Prof. Charles: Yes, Casey. Computers make the task feasible while also increasing efficiency for many other information management processes.
Donald: I think that the discussion on information management has clarified some questions for me. A little more clarification on the legal issues would really help.
Prof. Charles: Well, that is a great lead-in to the next topic, which is the medical records battleground. |
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Slide 7 |
Scene 4 Discussion on thje integrity and confidentiality of the patient record. |
Prof. Charles: The contents of the medical record must not be tampered with once an entry has been made; therefore, the record should be used wisely. Its purpose is to record the patient’s course of care.
A nurse tends to access the medical record more often than other healthcare professionals, simply because of the greater amount of time spent with the patient. Licensure rules and regulations contained in state statutes generally describe the requirements and standards for maintenance, handling, signing, filing, and retention of medical records.
Failure to maintain an accurate and complete medical record may affect the ability of an organization or physician third-party reimbursement. Under federal and state laws, the medical records reflect accurately the treatment. Thus, the medical records are important to the organization for medical, legal, and financial reasons.
Casey: I would say that the professionals must recognize that intentional alteration, falsification, or destruction of medical records is grounds for liability in a medical negligence suit.
Prof. Charles: Exactly…It is so important to remember that such negligence is grounds for actual malice and causes compensable harm.
Donald: Professor, in our discussion, you have provided us with a significant amount of information about allied health professionals and information management. It seems as though the integrity of patient records is important in maintaining the caregiver’s credibility.
Prof. Charles: Altered medical or business office records can create a presumption of negligence. . Casey: So anytime medical records are flawed with errors there is probably improper keeping of records?
Prof. Charles: Exactly. Beyond the medical record is a more complex issue: communication. All healthcare professionals who have access to the medical records have a legal, ethical, and moral obligation to protect the confidentiality of the information in the record. |
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Slide 8 |
Scene 5 Summary Picture of Casey and Donald as they speak. |
Prof Charles: We are just about out of time. Let’s go over what we learned in this lesson.
Healthcare professionals, regardless of field, are required to adhere to the prevalent standards of care required within their professions. This includes proper assessment, reassessment, diagnosis, treatment, and follow-up.
Many negligence lawsuits against hospitals arise from care administered in the emergency departments. Some of the most common reasons for these lawsuits are inappropriate administration of medications, failure to admit, failure to render care, and contradictory medical documentation.
Information management is the process of facilitating the flow of information within and among departments and caregivers. Although computers improve the ease and efficiency which data are compiled and shared, they also pose confidentiality risks.
Before we adjourn, are there any questions?
Donald: I have no questions. Thank you for the lesson today, Professor.
Casey: I have no questions as well. Thanks Professor.
Professor Charles: Excellent. Before you leave today, make sure to complete the threaded discussion for this week. Take care and I’ll see you again very soon!
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|
HSA 515, Lecture 6, Allied Health Professionals and Information Management |
||
|
Slide # |
Scene/Interaction |
Narration |
|
Slide 1 |
Scene 1 Professor Charles enters classroom and introduces the topics for today’s lesson and begins the lecture. |
Prof Charles: Hello everyone. Today, although there are a variety of legal issues, we are going to discuss an overview of selected health care organization departments or professions and information management systems capable of collecting and sharing essential patient health information.
Healthcare professionals are never exempt from the long arm of the legal system. Healthcare professionals are held to the prevailing standard of care required in their profession, which includes proper assessments, reassessments, diagnosis, treatment, and follow-up care.
Dental malpractice cases are usually related to patients who suffer from complications of a dental procedure. They can involve the improper treatment of dental infections or complications from the improper administration of anesthesia. Complications can also include damage to the nerves of the lower jaw, face, lips, and tongue. Injuries to sensations in the tongue can result from high-speed drills.
To significantly reduce the tens of thousands of deaths and injuries caused by medical errors every year, healthcare organizations must adopt information management systems that are capable of collecting and sharing all health information on patients and their health care.
Let’s first discuss emergency departments which are high-risk areas for hospitals. What are the objectives of emergency care regardless of severity?
Casey: The treatment must be as fast as possible so function is maintained or restored, scarring and deformity are minimized, and so forth.
Casey: In addition, the hospital emergency department has a duty to not only treat but admit patients on a timely basis.
Prof. Charles: Absolutely. What are some of the other potential liabilities of the hospital emergency department?
Casey: The Emergency Medical Treatment and Active Labor Act (EMTALA) forbids Medicare-participating hospitals from dumping any patient out of emergency departments. The patient who is presented to the emergency department should receive appropriate medical screening and treatment within the capability of the hospital emergency department. Patients who need specialized care not available in the department or hospital must be medically stabilized before being transferred to another hospital. The patient transfer must be medically appropriate.
Prof. Charles: What is another example of such liability?
Donald: There was a case in which a patient was admitted to the hospital emergency department after an automobile accident. The parents of the patient arrived and learned from the attending physician that the patient was okay to go home and get some rest. The physician had looked at the medical chart of another patient and missed the broken ribs, internal hemorrhaging, and falling blood pressure.
The parents took the son home and in a few hours developed a swollen abdomen and continued severe pain. The patient died at home and was pronounced dead later at the hospital. The court ruled that the attending physician’s review of the wrong record was a fatal mistake and resulted in a wrongful death.
Prof. Charles: Great job Donald! Now let’s take a closer look at preventing lawsuits and injuries in the emergency department. Lawsuits can be reduced by: Treating patients courteously and promptly; Treating all patients regardless of ability to pay; Triaging and treating seriously ill patients first; Communicating with the family and the patient to gain an accurate picture of the patient’s medical condition; Requiring consultations when determined necessary; and Making appropriate arrangements and communication, when required, for transfer. |
|
Slide 2 |
Check Your Understanding Which of the following is not the duty of the hospital emergency department? A. Patient presents to the hospital emergency department with a gunshot wound after robbing a bank. B. Patient leaves hospital emergency department against doctor’s orders and subsequently dies. C. Physician will not treat seriously injured non-paying emergency department patient Correct Feedback: B. Patient leaves hospital emergency department against doctor’s orders and subsequently dies.
Incorrect Feedback: A. Patient presents to the hospital emergency department with a gunshot wound after robbing a bank.
C. Physician will not treat seriously injured non-paying emergency department patient
|
|
|
Slide 3 |
Scene 2 Discussion between Prof Charles and students. |
Prof. Charles: Patients can be transferred only after they have been medically screened by a physician, stabilized, and cleared for transfer by the screening institution. Stabilized means “with respect to an emergency condition…to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.” A patient cannot be transferred unless the medical treatment available at another facility can reasonably be expected to outweigh the increased risk to the patient staying at the same hospital.
Physicians who do not want to comply with the transfer requirements of the Emergency Medical Treatment & Labor Act should only affiliate with hospitals that do not accept Medicare funds or do not have an emergency department.
The public not only relies on medical care provided by emergency departments, but also considers the hospital as a single entity providing all of its medical services.
Legislation in many states imposes a duty on hospitals to provide emergency care. If the public knows a hospital provides emergency care and relies on that knowledge, the hospital has a duty to provide those services to the public.
Healthcare organizations are expected to provide patients with pharmacy services. Doctors and nurses find it almost impossible to keep up with the information required for safe medication use. The pharmacist has become an essential resource in modern hospital practice.
Among the non-operative adverse events, medication errors are considered a leading cause of medical injury in the United States. Antibiotics, chemotherapeutic drugs, and anticoagulants are the three categories of drugs responsible for many drug-related adverse events. The activity of preparing, compounding, and retailing medications is controlled by the pharmacy and governed by state law. Pharmacists are required to be licensed by the state. The hospital patient’s drug regimens must be reviewed by the hospital pharmacist.
Casey: So, Professor Charles, can you tell us more about licensing health care professionals?
Prof. Charles: Absolutely! Licensure can be defined as the process by which some competent authority grants permission to a qualified individual or entity to perform certain specified activities that would be illegal without a license. The commonly stated objectives of licensing laws are to limit and control admissions to the different healthcare occupations and to protect the public from unqualified practitioners by promulgating and enforcing standards of practice within the professions.
Donald (interrupts): Just to be clear, the certification of healthcare professionals is the recognition by a government or professional association that an individual’s expertise meets the standards of that group. Some professional groups establish their own minimum standards for certification in those professions that are not licensed by a particular state. Certification by an association or group is a self-regulation credentialing process.
Prof. Charles: Yes, but licensing boards have the authority to suspend or revoke the license of healthcare professionals found to have violated specific norms of conduct. Groups or associations which self-regulate credentialing can revoke or suspend certification of a healthcare professional.
Casey: I am still not quite clear on the multidisciplinary approach to patient care. Can you elaborate on it some more
Prof. Charles: Sure….Do patients believe that care is always well coordinated? Do pharmacists find it necessary to contact the doctor when there are questions regarding dosage? Would it be helpful for the prescribing physician to discuss his patient’s needs with the treating therapist?
Regardless of the profession or healthcare setting, a multi-disciplinary approach to patient care is a must in any organization. Healthcare professionals need to consider and discuss what questions they might ask if they were a patient undergoing treatment.
.
|
|
Slide 4 |
Check Your Understanding To significantly reduce the tens of thousands of deaths and injuries caused by medication errors every year, health care organizations must adopt ____________ that are capable of collecting and sharing essential health information on patients and their care A. Information systems B. Hand written notes Correct Feedback:
Incorrect Feedback: B. Hand written notes is incorrect. Hand written notes can be misread and often not readily available for caregivers resulting in injuries to the patient by misdiagnosis, errors in drug administering, and delayed treatment.
|
|
|
Slide 5 |
Check Your Understanding A Healthcare records are the property of the_____________ and are maintained for the benefit of the patient.
B. Provider of care. C. Federal government. D. Licensing agency Correct Feedback: B. Provider of care is the correct answer. Patients have a right to access their records and obtain copies. Failure to release records can lead to legal action by the patient. Incorrect Feedback: A. Incorrect. State C. Incorrect. Please try again. D. Incorrect. Please try again. Remember. Ownership resides with the organization rendering treatment. |
|
|
Slide 6 |
Scene 3 Discussion of information management and the law |
Prof. Charles: Now let’s discuss information management and the law.
Can anyone explain the rights of patients and their medical record?
Casey: I think I can. Patients may have access to review and obtain copies of their records. Access to information includes records maintained or possessed by a healthcare organization or healthcare provider such as a physician’s office, who has treated or is treating a patient. Organizations and physicians can withhold records if the information could reasonably be expected to cause harm to the patient. For example, patients in psychiatric hospitals, institutions for the mentally disabled, or alcohol and drug treatment programs.
Prof. Charles: Very good Casey! That is an excellent explanation.
Donald: Prof. Charles, what about the retention of medical records?
Prof. Charles: Donald that is a great question. The length of time medical records must be retained varies by state. One state may require the medical record be retained for five years and another for seven years. Healthcare organizations must take into consideration such things as state law; Needs of its patients; Future needs for such records; and Legal considerations of having the record available in the event of a lawsuit.
Casey: Do computers help in retaining medical records?
Prof. Charles: Yes, Casey. Computers make the task feasible while also increasing efficiency for many other information management processes.
Donald: I think that the discussion on information management has clarified some questions for me. A little more clarification on the legal issues would really help.
Prof. Charles: Well, that is a great lead-in to the next topic, which is the medical records battleground. |
|
Slide 7 |
Scene 4 Discussion on thje integrity and confidentiality of the patient record. |
Prof. Charles: The contents of the medical record must not be tampered with once an entry has been made; therefore, the record should be used wisely. Its purpose is to record the patient’s course of care.
A nurse tends to access the medical record more often than other healthcare professionals, simply because of the greater amount of time spent with the patient. Licensure rules and regulations contained in state statutes generally describe the requirements and standards for maintenance, handling, signing, filing, and retention of medical records.
Failure to maintain an accurate and complete medical record may affect the ability of an organization or physician third-party reimbursement. Under federal and state laws, the medical records reflect accurately the treatment. Thus, the medical records are important to the organization for medical, legal, and financial reasons.
Casey: I would say that the professionals must recognize that intentional alteration, falsification, or destruction of medical records is grounds for liability in a medical negligence suit.
Prof. Charles: Exactly…It is so important to remember that such negligence is grounds for actual malice and causes compensable harm.
Donald: Professor, in our discussion, you have provided us with a significant amount of information about allied health professionals and information management. It seems as though the integrity of patient records is important in maintaining the caregiver’s credibility.
Prof. Charles: Altered medical or business office records can create a presumption of negligence. . Casey: So anytime medical records are flawed with errors there is probably improper keeping of records?
Prof. Charles: Exactly. Beyond the medical record is a more complex issue: communication. All healthcare professionals who have access to the medical records have a legal, ethical, and moral obligation to protect the confidentiality of the information in the record. |
|
Slide 8 |
Scene 5 Summary Picture of Casey and Donald as they speak. |
Prof Charles: We are just about out of time. Let’s go over what we learned in this lesson.
Healthcare professionals, regardless of field, are required to adhere to the prevalent standards of care required within their professions. This includes proper assessment, reassessment, diagnosis, treatment, and follow-up.
Many negligence lawsuits against hospitals arise from care administered in the emergency departments. Some of the most common reasons for these lawsuits are inappropriate administration of medications, failure to admit, failure to render care, and contradictory medical documentation.
Information management is the process of facilitating the flow of information within and among departments and caregivers. Although computers improve the ease and efficiency which data are compiled and shared, they also pose confidentiality risks.
Before we adjourn, are there any questions?
Donald: I have no questions. Thank you for the lesson today, Professor.
Casey: I have no questions as well. Thanks Professor.
Professor Charles: Excellent. Before you leave today, make sure to complete the threaded discussion for this week. Take care and I’ll see you again very soon!
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