when a legal report is mandated what to say to patient

Mandated Reporting First, if the client expresses that they will harm another person it trigger an incident of mandated reporting. In California this is now considered to be the duty to protect. If the client has told the therapist that they intend to harm another, the therapist has a duty to protect the persons who may be involved.

Full Answer

Are you legally obligated to report what your clients say during therapy?

However, there are some specific situations when mental health professionals are legally obligated to report something that a client does or says during a therapy session. “I like to tell my clients that therapy is kind of, ‘What happens in Vegas stays in Vegas.’

Should there be a mandatory reporting law for violent patients?

Mandatory reporting laws, say some professionals, may discourage people from seeking professional help or fully disclosing their intentions; or providers may be reluctant to treat potentially violent patients because they fear liability for failure to properly fulfill the duty to warn.

What is mandated reporting in psychiatry?

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital. Mandated reporting refers to the legal obligation to report abuse. Mandated reporters are individuals or agencies that are legally required to make these reports.

Is mandatory reporting in Nursing required by law?

Additionally, mandatory reporting in nursing is required by law. As a provider, ensuring patient confidentiality is of the utmost importance in practice; however, mandatory reporting takes precedence.

What are two things a physician is obligated to tell a patient under the informed consent doctrine?

In two informed consent cases following Canterbury, physicians have also been required to disclose (1) personal or economic interests that may influence their judgment (Gates v. Jenson) [6] and (2) all diagnostic tests that may rule out a possible condition (Jandre v. Physicians Insurance Co of Wisconsin) [7].

What should be included in a patient report?

A structured format incorporating elements of background information, medical history, physical examination, specimens obtained, treatment provided and opinion is suggested.

What information does the patient require in order to give informed consent?

The information that must be given to a person includes:the diagnosis and likely outcome ('prognosis') of the condition.an explanation of the recommended treatment.the risks of the treatment and common side effects.possible complications of the treatment.More items...

What information should be provided to a patient prior to undergoing any procedure?

What Is Informed Consent?The name of your condition.The name of the procedure or treatment that the health care provider recommends.Risks and benefits of the treatment or procedure.Risks and benefits of other options, including not getting the treatment or procedure.

How do you take care of a patient report?

Document the patient's history completely. Remember bystanders or those close to the patient can often provide valuable information about the patient....Check descriptions. ... Check (and recheck) spelling and grammar. ... Assess your chief complaint description. ... Review your impressions. ... Check the final details.

How do you write a case report?

Case reports should encompass the following five sections: an abstract, an introduction with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, and a brief summary of the case and a conclusion.

How do you ask a patient for consent?

0:395:12Informed consent in health care - YouTubeYouTubeStart of suggested clipEnd of suggested clipIf your health worker wants to test or treat you they must ask you for your consent. First informedMoreIf your health worker wants to test or treat you they must ask you for your consent. First informed consent is when you clearly.

What are the five legal elements of an informed consent?

Obtaining informed consent in medicine is process that should include: (1) describing the proposed intervention, (2) emphasizing the patient's role in decision-making, (3) discussing alternatives to the proposed intervention, (4) discussing the risks of the proposed intervention and (5) eliciting the patient's ...

What are the 4 principles of informed consent?

There are 4 components of informed consent including decision capacity, documentation of consent, disclosure, and competency.

How do you explain a procedure to a patient?

Introduction. Introduce yourself appropriately to the patient, check if they have any prior knowledge of the procedure, if they have ever had the procedure before, or if they know someone who has. Then explain the purpose of the procedure, its approximate duration, and how they can expect to feel immediately afterwards ...

What should the patient be told about a procedure?

The information that must be given to you as a patient includes:The diagnosis and likely outcome (prognosis) of your condition.An explanation of the recommended treatment.The risks of the procedure and common side effects.Possible complications.More items...

What is written consent in healthcare?

When your healthcare provider recommends specific medical care, you can agree to all of it, or only some of it. Before the procedure, you'll have to complete and sign a consent form. This form is a legal document that shows your participation in the decision and your agreement to have the procedure done.

Who Is a Mandated Reporter?

Since laws vary by state, there are some jurisdictional differences about who is required to make these reports. Typically, this includes the following individuals:

What Are Mandated Reporters Required to Report?

Although states vary on the specifics, mandated reporters exist to ensure safety by reporting suspected abuse. The local department of human services (sometimes called Child Protective Services or Department of Social Services) investigates the report and determines whether intervention is necessary.

What Other Things Might Be Reported?

Sometimes, information might not fall under mandated reporting, but an individual might still disclose it for safety or legal reasons.

A Word From Verywell

The goal of mandated reporting is to ensure safety for vulnerable populations and prevent abuse. To learn more about your state's mandated reporting laws, check your government website. You can learn what circumstances require a report and which professionals and organizations are mandated reporters.

How does a firearm affect a physician?

Depending on their personal experience with guns, physicians might have varying levels of concern about or comfort with the implications of a firearm’s involvement in a given case . They might also be hesitant to question a patient further on the topic, as they might be concerned about offending the patient by asking about what many perceive to be a private issue. However, ascertaining the types of guns owned, how they are stored, and if the patient has any intentions of using them are important components of risk assessment.

What is the Tarasoff statute?

For example, California Civil Code 43.92, known as the “Tarasoff statute,” requires that if a patient makes “a serious threat of physical violence against a reasonably identifiable victim” to a psychotherapist, that psychotherapist is required to take steps to protect the intended victim [18].

Why is mandatory reporting required?

Mandatory reporting of persons believed to be at imminent risk for committing violence or attempting suicide can pose an ethical dilemma for physicians, who might find themselves struggling to balance various conflicting interests. Legal statutes dictate general scenarios that require mandatory reporting to supersede confidentiality requirements, but physicians must use clinical judgment to determine whether and when a particular case meets the requirement. In situations in which it is not clear whether reporting is legally required, the situation should be analyzed for its benefit to the patient and to public safety. Access to firearms can complicate these situations, as firearms are a well-established risk factor for violence and suicide yet also a sensitive topic about which physicians and patients might have strong personal beliefs.

Why did Thomas struggle to sleep?

After a painful breakup with his long-time girlfriend, Thomas struggled to get over feeling angry about his girlfriend’s decision to end their relationship. Specifically, Thomas was unable to sleep well, despite trying numerous over-the-counter sleep aids. He decided to make an appointment with Dr. B to get a prescription for something that might help.

When was the HIPAA Act passed?

In 1996 , the federal government passed the Health Insurance Portability and Accountability Act ( HIPAA) to standardize the expectations of patient confidentiality surrounding protected health information (PHI), which comprises any health care information that can be linked to a specific individual, such as diagnostic or treatment information [4]. With this increased regulation came increased sanctions for violations and physicians’ growing concerns about both their ethical and legal duties concerning confidentiality [5]. However, HIPAA’s implementing regulations describe particular exceptions in which it is appropriate to break confidentiality, particularly in circumstances when a failure to do so could result in harm to the patient or to society [6].

Who is Amy Barnhorst?

Amy Barnhorst, MD is an assistant clinical professor of psychiatry at the University of California, Davis, where she is also an emergency and inpatient psychiatrist who conducts violence and suicide risk assessments as part of her clinical care. She conducts research on the interface between firearm violence, suicide, and mental illness.

Do medical laws fit into real life cases?

Despite their attempts at specificity, these laws often do not fit neatly onto real-life patient cases. In some jurisdictions, the statements made by the patient can meet the threshold at which a physician is mandated to report in order to warn or protect a potential victim.

When Did Mandatory Reporting in Nursing Begin?

Mandatory reporting was not conceptualized and implemented solely for the healthcare professions, in fact, it was created for educators, law officials, and various other professionals, too. Essentially, any career that works with civilians must follow a mandatory reporting protocol.

What Are Some of the Common Signs and Symptoms of Possible Abuse or Neglect?

According to the Mandatory Reporting Guide offered by the Iowa Department of Human Services (DHS), there are various physical and behavioral signs of child abuse or neglect that all mandatory reporters should be aware of; some of these include:

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What is the California law on elder abuse?

California Law, under the Welfare & Institutions Code for Elder Abuse, provides for mandated reporting of physical abuse, neglect, self-neglect, sexual abuse, mental suffering, financial abuse, isolation, abandonment or abduction of an elder or dependent adult. More specifically the code states that when the caretaker has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool.

What is the CANRA law?

Harm of a child. The California Child Abuse and Neglect Reporting Act (“CANRA,” Penal Code sections 11164-11174.4) requires certain professionals, mandated reporters, to report known or suspected instances of child abuse or neglect to law enforcement.

What is the definition of neglect in California?

In California Penal code Article 2.5 Child Abuse and Neglect Reporting Act section 11165.2, the definition of neglect is the general negligent failure of a person having care or custody of a child to provide adequate food…or medical care.

What is the duty to protect in California?

First, if the client expresses that they will harm another person it trigger an incident of mandated reporting. In California this is now considered to be the duty to protect. If the client has told the therapist that they intend to harm another, the therapist has a duty to protect the persons who may be involved.

What is mandatory reporting?

Mandated reporting may be invoked if there is a reasonable suspicion that you are likely to kill yourself. It can also happen where there is a reasonable suspicion that you are might harm yourself. There is no Federal law that mandates reporting for suicide risk. Each state has their own laws which cover if reporting is required. They will also define who is required to report and how they are to report. In some cases there may be professions that have rules regarding the reporting requirements in cases such as this. Confidentiality laws also vary by state in terms of when parental consent must be attained. In most cases if there is imminent risk, it would override parental consent.

How long does it take to get a written report from a hospital?

A written report must be sent within 48 hours of the incident. The California act specifically sets out guidelines when state report requirements are triggered. When patient is : “suffering from any wound or other physical injury inflicted by his or her own act.

Does a therapist have to protect against law enforcement?

In 2013 this was changed to become specific. The law now requires that the therapist take measure to protect. In the case where the therapist believes that contacting law enforcement will endanger the client, other measures may be taken. If the Therapist decides to contact law enforcement, they will have immunity.

What are the statutes for child abuse?

Statutes include child abuse and neglect reporting statutes, medical neglect of children and the elderly, elder abuse in the community or in nursing homes reporting laws, and domestic violence. Reporting statutes have certain conditions and protections the reporter must meet and possesses in order to ensure that the reporting is not done ...

What is a good faith belief?

Have a “good faith belief” or a “reasonable suspicion” that an injury or injuries are the result of abuse or neglect ; The reporter enjoys immunity from civil, criminal and professional licensure actions if the report meets criteria #1;

When was the Avoiding Liability Bulletin issued?

Avoiding Liability Bulletin – April 2013. Federal and state laws require that certain individuals, particularly those who work in health care, with the elderly, with children, and other vulnerable populations, have an affirmative duty to report to a specified state agency when violence occurs against those populations.

What happens if a therapist fails to take reasonable steps to protect the intended victim from harm?

“If a therapist fails to take reasonable steps to protect the intended victim from harm, he or she may be liable to the intended victim or his family if the patient acts on the threat ,” Reischer said.

Do you have to report child abuse to a therapist?

“If a client experienced child abuse but is now 18 years of age then the therapist is not required to make a child abuse report, unless the abuser is currently abusing other minors,” Mayo said.

Can a therapist report a patient's intent to harm someone else?

A therapist may be forced to report information disclosed by the patient if a patient reveals their intent to harm someone else. However, this is not as simple as a patient saying simply they “would like to kill someone,” according to Jessica Nicolosi, a clinical psychologist in Rockland County, New York. There has to be intent plus a specific identifiable party who may be threatened.

Do therapists have to disclose information in court?

For instance, Reed noted that even if a wife is cheating on her husband and they are going through a divorce, the therapist has no legal obligation whatsoever to disclose that information in court. The last thing a therapist wants to do is defy their patient’s trust.

Should clients withhold anything from their therapist?

“Clients should not withhold anything from their therapist, because the therapist is only obligated to report situations in which they feel that another individual, whether it be the client or someone else, is at risk,” said Sophia Reed, a nationally certified counselor and transformation coach.

What is the duty of a mental health professional to protect against violent behavior?

A mental health professional has the duty to warn of or take reasonable precautions to provide protection from violent behavior only if the patient communicates an actual threat of physical violence by specific means and against a clearly identified or reasonably identifiable victim.

When can a holder of a patient's medical records disclose information?

The holder of the records may disclose information when the patient has communicated a serious threat of serious physical injury against a reasonably identifiable victim, the person with knowledge of the threat may disclose the threat to the potential victim or to any law enforcement officer, or both.

When does the duty to predict, warn, or take reasonable precautions to provide protection from, violent behavior arise?

The duty to predict, warn of, or take reasonable precautions to provide protection from, violent behavior arises only when a client or other person has communicated to the licensee a specific, serious threat of physical violence against a specific, clearly identified or identifiable potential victim.

What is client privilege in behavioral health?

Behavioral health professional - client privilege does not extend when the professional has a duty to (1) inform victims and appropriate authorities that a client's condition indicates a clear and imminent danger to the client or others; or (2) to report information required by law.

What is the responsibility of mental health professionals to communicate the threat to the victim?

Mental health professionals must make a reasonable effort to communicate, in timely manner, the threat to the victim and notify the law enforcement agency closest to the patient's or victim's residence and supply a requesting law enforcement agency with any information concerning the threat.

What is the Immunity for Mental Health Professionals?

Immunity for mental health professionals for release of information via 36-504 or 36-509. A release of information via 36-504 or 36-509 shall, at the request of the patient, be reviewed by a member of his family or a guardian. Section provides for appeal procedures.

When did California impose a legal duty on psychotherapists?

California courts imposed a legal duty on psychotherapists to warn third parties of patients’ threats to their safety in 1976 in Tarasoff v. The Regents of the University of California.

Case

Commentary

• Since the beginnings of Western medicine in the days of Hippocrates, patient confidentiality has been an important ethical responsibility of the physician. In the Hippocratic Oath, considered by many to be the first known guidelines written for medical ethics, physicians vow that “What I may see or hear in the course of the treatment or even outsid...

See more on journalofethics.ama-assn.org

Disclosing Protected Health Information

Counseling Patients About Firearm Safety

When Is Reporting Required?

Conclusion

States That by Law Require Mandatory Notification of Adverse Events to Patients

• Nevada NRS §439.855 (2004) Florida Stat. §395.1051 (2004) New Jersey Stat. §26:2H-12.25 (2005) Pennsylvania 40 P.S. §1303.308(b) (2004) Vermont § 310 (2006) The above are states with laws specifically addressing mandatory reporting. There also are states like Ohio that simply require physicians to obey the AMA's code of ethics, and that code requir...

See more on patient-safety.com

Federal Regulation Mandates Reporting in Hospitals with Virtually No Compliance

There Even Is A Regulation Specific to Medical Devices