Law, Documentation & Ethics

Law, Documentation & Ethics RTEC 93 Veinpuncture and Pharmacology for Radiologic Technologists

ASRT • Includes venipuncture and IV medication administration in the curriculum guidelines for the educational opportunities offered to technologists. • Standards of Practice for Radiography

American College of Radiology (ACR) • Additional support for the administration of medications and venipuncture as part of the technologist’s scope of practice if found in the 1987 Resolution No. 27

Veinpuncture Laws • CALIFORNIA HEALTH AND SAFETY CODE • HEALTH AND SAFETY CODE SECTION 106955-107111

Hospital Policies for Radiologic Technologists • Competency in venipuncture and IV contrast administration requires the completion of a formal course of instruction and supervised clinical practice and evaluation

Standard of Care • Degree of skill (proficiency), knowledge, and care ordinarily possessed & employed by members in good standing within a profession. • To test whether the standard of care has been met, one must determine what a reasonable, prudent practitioner would have done under similar circumstances.

Causes of Legal Action • Approx 10% of all medical negligence claims are somehow related to diagnostic imaging. • Medical Negligence – failure to use such care as a reasonably prudent health care professional would use in similar circumstances.

Four Elements to Prove Negligence • Must establish a duty to the patient by the health care provider • Breach of this duty by an act or by failing to perform some act. • A compensable injury • A causal relation between the injury and the breach of duty.

Cause of Legal Action • Tort – Civil wrong committed by one individual against another. May be classified as either intentional or unintentional. This type of claim arises from a breach of duty. ex: less than optimal care, threatened, or injured in department • Usually based upon legitimate concerns of negligent care or claims of assault, battery, or false imprisonment.

Cause of Legal Action • Assault – Any willful attempt or threat to inflict injury on the person and any intentional display of force that would give the victim reason to fear or expect immediate bodily harm. • Battery – An unlawful touching of another that is without justification or excuse. Ex: a technologist performs an exam or touches a patient without that patient’s permission, even if no injury arises from such contact.

Cause of Legal Action • False Imprisonment – Conscious restraint of another without proper authorization, privilege, or consent. The more common claim of false imprisonment arises when a person is restrained against his or her will. • Defamation – Holding up a person to ridicule, scorn, or contempt in a respectable & considerable part of the community.

Corporate Liability • Requires the hospital or health care entity to be responsible for the quality of care delivered to consumers. • Health care corp. must assess & evaluate the quality of care delivered & must be prepared to make changes as needed. • The corp. may be required to intervene if suboptimal care is being provided by one of its independent contractors.

Informed Consent • A person’s agreement to allow something to happen (i.e surgery) that is based on full disclosure of the facts: knowledge of benefits, risks, and alternatives to the procedure. • Required when a patient is subjected to any type of invasive procedure. • If the pt consents to a procedure & then revokes the consent, the doctor must stop the procedure.

The Law Every human being of adult years and sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages.

Six functions of this Law • Protects individual autonomy • Protects the patient’s status as a human being • Avoids fraud and duress • Encourages health care practitioners to carefully consider their decisions • Fosters rational decision making by the patient, and • Involves the public in medicine

The Health Record in Court • The radiograph as evidence • Dark/light radiograph • Mis-marked films • Wrong patient information

Documentation • In court, if you testify that you properly assessed the patients medical risk and obtained consent from the patient verbally prior to the examination; will that serve as meeting the Technologist Standard of Practice?

Documentation Federal requirements and the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) require that the medical staff of an institution have bylaws, rules and regulations that include a provision for accurate and complete medical records with the original copies of documents in the patient record.

The record is a means of communication between the healthcare professionals who are treating the patient.

Must Include: • Patient identification date • Medical history of the patient, including chief complaint; present illness or injury; relevant past, family and social histories; and inventory by body systems • Report of relevant physical examination • Diagnostic and therapeutic orders • Clinical observations, including results of therapy

Reports of diagnostic and therapeutic procedures and test as well as their results • Evidence of appropriate informed consent (when consent is not obtainable, the reason should be entered in the record) • Conclusions at termination of hospitalization or evaluation of treatment, including any pertinent instructions for follow-up care

Charting Drug Information • Any time a drug is administered to an inpatient it must be charted • Information includes: • Drug name • Dose of the drug • Route of administration (if parenterally, then the side of injection) • Date & Time

Documentation • The five rights of medication administration is to be included in every patient’s permanent medical record. • The size, type and location of the needle, number of venipuncture attempts; and the identity of the health care personnel who performed the procedure.

Document Meds Given • 5 rights of medication administration: • The right patient • The right medication • The right route • The right amount • The right time

Example • 4-25-2007 at 0900 a venous access of Mr. Jones was performed using an 20-gauge antiocatheter. The access was established in the antecubital of the left arm after one attempt. Then 100 ml of Isovue 300 was administered by IV push via the access. The patient tolerated the injection procedure and medication without complaints of pain and with no unexpected side affects. K. Clark, R.T.

Charting Exam Completion • M.D.’s order in patient’s chart should be verified prior to examination • Document exam completion next to M.D.’s written order • Ex: 4/25/07, 1300, 2 view CXR complete K. Clark (RT)

HIPPA • The Health Insurance Portability and Accountability Act of 1996 mandates that federal laws or regulations ensure the confidentiality of medical records. • Patients or representatives should have access to all records except in the event the provider feels that it is not in the best interest of the patient’s health to have access or if the knowledge of the health care information could cause danger to the life or safety of any person.

HIPPA • Within radiology: Technologists are sometimes asked by patients if they can examine their records while in transit, waiting for a procedure or undergoing an examination. The record information should not be shared with the patient in this fashion as this may lead to misinterpretation of information.

Documentation • As applied to radiology: • Assess the order: procedure requested, identifying information, doctor • The report: results are kept in patient chart

The Importance of a Professional Ethic Ethics: the systematic study of rightness and wrongness of human conduct and character as know by natural reason Professional Ethic: the ethical conduct of a profession

Ethical Dilemmas A situation requiring moral judgment between two or more alternatives; there are two or more competing moral norms present, creating a challenge about what to do

Ethical Analysis • 1. identifying the problem • 2. developing alternative solutions • 3. selecting the best solution • 4. defending your selection

Professional Ethic • Conduct must support the emotional and physical needs of the patient • Patient privacy and dignity or even the simple right to be told the truth must be adhered to • Assist in providing accurate information which enables physicians to make proper diagnosis

REMEMBER Radiology Technologist are legally liable for their actions in the daily performance of diagnostic procedures. Health care practitioners who do not remain current in the field or who do not follow the accepted standard may be liable under the legal theory of medical negligence.

Identifying the Problem • Thoroughness in problem identification, looking at every possible twist or nuance in a given situation

Developing Alternative Solution • Attempt to exhaust all possible pathways to a resolution of the dilemma, taking care to view the dilemma from the perspective not only of the patient and the patient’s family but also the health care professionals and administrators to whom they entrust their care.

Selecting the Best Solution • Most challenging step • It is a personal activity that involves choosing an alternative not only based on widely held moral stands but one that is also in full accord with your own individual value system

Defending Your Selection • Explain the basis for your ethical decision in terms that you can justify to colleagues and patients alike

Situation Judgment Tests – SJT’s“I Think Dr. Jones Misread the Film” You have just finished a routine radiologic procedure on Mrs. Green. As you develop the film, it becomes clear that Mrs. Green is probably suffering from a rare form of bone disease. Dr. Jones, a young resident, glances at the film and smiles. “I didn’t think Mrs. Green had anything to worry about,” he says. “That joint pain she was complaining about must be all in her head.” Later, you see Dr. Jones talking to Mrs. Green’s family. He is smiling and joking with them as he signs Mrs. Green’s discharge papers. Shaken, you mutter to yourself, “I think Dr. Jones misread the film.” What should you do”

Law, Documentation & Ethics