Describe the contents of medical records

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Reference no: EM133670280

Assignment:

Please REVIEW QUESTIONS from the textbook.

Part 1

Explain the importance of information management planning.

  • Describe the contents of medical records.
  • Discuss why it is important to maintain complete and accurate medical records.
  • Discuss how the privacy act of 1974 and the health insurance portability and accountability act of 1996 safeguard a patient privacy.
  • Explain the ownership of and who can access a patient medical records.
  • Identify the advantages and disadvantages of electronic medical records.
  • Describe why the medical records 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.

Part 2

  • Differentiate among verbal, written, and implied consent.
  • Describe the role of the patient, physician, nurse, and hospital in obtaining informed consent.
  • Explain how consent differs among competent patients, minors, guardians, and incompetent patients.
  • Explain the available defenses For defendants as it related to informed consent.
  • Can a patient consent to a procedure and then withdraw it.

Part 3

  • Discuss the rights and responsibility of patients as reviewed in this chapter.
  • Why should caregivers consider themselves as patient advocates.
  • Describe what patients can do to help prevent medical errors.

Part 4

  • Describe how ethical theories differ and how ethical principles are helpful to caregivers and the ethics committee in resolving ethical dilemmas.
  • Describe how spirituality and religion help shape ones healthcare choices.
  • Describe the term situational ethics and how decisions can change as circumstances change.
  • Describe the consultative role of the ethics committee and when addressing ethical dilemmas.

Part 5

1. Describe how patients autonomy in making healthcare decision has been impacted by case law and legislative enactments.

  • Discuss the following concepts: euthanasia, advance directives, futility of treatment, withholding and withdrawal of treatment, and do not resuscitate orders.
  • Explain end of life issues as they related to autopsy, organ donations, research experimentation and clinical trial.
  • Describe how much a genetics and stem cell research con have and impact on end of Life issues.
  • Discuss the importance of genetic markers.
  • Explain why the genetic information non discrimination act was enacted.

Part 6

  • Discrete various form of child abuse, how to recognize it and reporting requirements.
  • Describe various forms of elder abuse, how to recognize it and reporting requirements.
  • Describe the signs of spousal abuse and the role of nurse in addressing the patients safety needs.
  • Describe what actions hospital should take to ensure that caregivers addresses suspicion of spousal abuse.
  • Discuss the importance of reporting births and deaths.
  • Explain why it is important to report communicable diseases, adverse drug reactions, and infectious diseases.
  • Explain how and why physician incompetence is reported.
  • Explain the importance of incident reporting, sentinel events, and the purpose of root causes analyses.

Source: Legal Aspects of Health Care Administration, 14th edition

Reference no: EM133670280

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