if an action or procedure that was performed on a patient is not recorded on the written report

What is unauthorized medical treatment?

Medical treatment could be unauthorized because the doctor didn’t fully explain either the procedure or the risks associated with the procedure. First, the patient must show that the doctor performed the treatment or procedure without her informed consent.

What happens if a medical record is late?

If a medication, assessment, procedure, etc., is not timely then other care providers do not have an accurate account of a patient’s condition which may lead to poor outcomes, including death. In the event of a malpractice lawsuit, a plaintiff’s attorney will argue that documentation that is late by hours or days is self-serving.

When is documentation not contemporaneous with patient care and patient outcomes?

The documentation is not contemporaneous with your nursing assessment, patient care, and patient outcomes. In other words, if it’s not documented when it happened, maybe it didn’t happen that way.

What are the consequences of falsifying medical records?

The ramifications of falsifying records may be a nursing liability, encumbered license, or loss of your license. Another consequence is, your veracity as a nurse will be severely compromised. Documentation that is a complete, accurate, timely account of a patient’s condition or status is your best defense against litigation.

Which of the following components are needed to prove negligence EMT?

In order to establish negligence, you must be able to prove four “elements”: a duty, a breach of that duty, causation and damages.

Which of the following most accurately describes negligence?

Which of the following most accurately describes negligence? performance of care that does not meet the accepted standards.

What does an untidy patient care report indicate?

In the eyes of the courts, an incomplete or untidy patient care form indicates: inadequate patient care was administered. Shortly after you load your patient, a 50-year-old man with abdominal pain, into the ambulance, he tells you that he changed his mind and does not want to go to the hospital.

What is an EMT's primary ethical consideration?

What is an​ EMT's primary ethical​ consideration? Making patient care and the​ patient's well-being a priority. Documents signed by a patient that communicate his or her wishes regarding medical care are​ called: advance directives.

Whats the difference between malpractice and negligence?

When a medical provider's actions or inactions fail to meet the medical standard of care, their behavior constitutes medical negligence. If their medical negligence causes their patient to suffer an injury, it becomes medical malpractice.

What is the difference between negligence and breach of duty?

Negligence Claims The typical elements are that the defendant owed a duty of care to the victim, the defendant breached that duty of care, the breach caused the plaintiff to sustain injury and the victim incurred damages as a result. The breach of the duty of care is predicated on what the duty of care is.

What the patient care report represents?

Patient care report or “PCR” means a computerized or written report that documents the assessment and management of the patient by the emergency care provider in the out-of-hospital setting. “ Pharmacy-based” means that ownership of the drugs maintained in and used by the service program.

Which of the following is not included in patient PHI information?

PHI only relates to information on patients or health plan members. It does not include information contained in educational and employment records, that includes health information maintained by a HIPAA covered entity in its capacity as an employer.

What is a knowledge based failure?

Knowledge-based failure - actions that are intended but do not achieve the intended outcome due to knowledge deficits.

Which of the following elements of patient information is not provided in a radio report but must be provided in a patient care report?

In which section of a patient care report would an EMT record the time that the emergency unit left the scene? Which of the following elements of patient information is not provided in a radio report but must be provided in a patient care report? A. billing information.

What is a set of regulations and ethical considerations that define?

The collective set of regulations and ethical considerations may be referred to as scope of practice because it defines the scope, or extent and limits, of the job one does.

When confronted with an issue regarding patient consent or restraining a patient which of the following concepts should guide your decision making?

When confronted with an issue regarding patient consent or restraining a patient, which of the following concepts should guide your decision making? Provide for the patient's well-being. A patient is injured but refuses to be transported by ambulance.

What does it mean when a patient tells you he changed his mind?

The correct answer is: A. decomposition of the body's tissues. Shortly after loading your patient, a 50-year-old man with abdominal pain, into the ambulance, he tells you that he changed his mind and does not want to go to the hospital. He is conscious and alert and has no signs of mental incapacitation.

What does it mean when a patient regains consciousness?

The patient tells you that he feels fine and does not want to go to the hospital. Under these circumstances, you should:

Why do nurses stay after their shift?

More and more nurses feel staying after their shift to get caught up on patient documentation is a necessity, not a choice.

Is it a timely document to document a shift?

The answer is no. Whether waiting to document until the end of shift or documenting ahead to stay on top of it, the documentation is not “timely.”. The documentation is not contemporaneous with your nursing assessment, patient care, and patient outcomes.

Is untimely documentation a fraud?

Untimely documentation is considered false, untrue, misleading, and deceitful. Untimely documentation may also be considered fraud.

Can you falsify your nursing license in Minnesota?

It is imperative that as a nurse licensee, you never falsify nursing documentation, or any document, in relation to your nursing practice.

Why is medical treatment unauthorized?

Medical treatment could be unauthorized because the doctor didn’t fully explain either the procedure or the risks associated with the procedure. First, the patient must show that the doctor performed the treatment or procedure without her informed consent.

What is the first step in a patient's medical history?

First, the patient must show that the doctor performed the treatment or procedure without her informed consent. Second, the patient has to show that had she known about the risks of the procedure, she would’ve decided not to have it done and, therefore, avoided the injury.

What happens if a doctor doesn't give consent?

If a doctor fails to obtain informed consent for non-emergency treatment, he or she may be charged with a civil offense like gross negligence and/or a criminal offense such as battery or gross negligence which is the unauthorized touching of the plaintiff's person. In a civil suit, the patient would have to show two elements. Medical treatment could be unauthorized because the doctor didn’t fully explain either the procedure or the risks associated with the procedure. First, the patient must show that the doctor performed the treatment or procedure without her informed consent. Second, the patient has to show that had she known about the risks of the procedure, she would’ve decided not to have it done and, therefore, avoided the injury.

What is informed consent?

Informed Consent. Virtually all states have recognized, either by legislation or by common law, the right to receive information about one's medical condition, treatment choices, risks associated with the treatments, and prognosis.

Is informed consent legal?

The informed consent process isn’t only an ethical obligation for doctors -- it is also a legal one. State laws often take a patient-centered approach.

Can a minor give consent to medical treatment?

Minors, unlike adults, are generally presumed to be incompetent. Therefore, they are unable to give consent to medical treatment and procedures. In these cases, the parent or guardian of the child must give consent on the minor’s behalf.

Is a patient considered competent?

In order to give his or her informed consent, a patient must be competent. Generally, adults are presumed to be competent. However, this presumption can be challenged in cases of mental illness or other impairments. Minors, unlike adults, are generally presumed to be incompetent.

Identify Discontinued Procedures

Inpatient coders must be able to recognize whether a procedure was performed in its entirety to be able to code it properly. A discontinued procedure is one that is canceled or not fully accomplished under the procedure definition. To determine if a procedure was discontinued, look for the following key terms in the documentation:

Case Study 1

Procedure note: A 37-week-old baby weighing 2,120 grams. Prenatal diagnosis of two life-threatening congenital anomalies associated with a chromosomal deletion. The infant was born via spontaneous vaginal delivery and intubated immediately and placed on mechanical ventilation.

Case Study 2

Procedure note: A 54-year-old male was admitted due to shortness of breath associated with a cough and low oxygen saturation. Patient was found to have left lower lobe consolidation indicative of pleural effusion. A thoracentesis was ordered. Plan: thoracentesis by the interventional radiologist. Hold Eliquis.