Law, Documentation

1
Law, Documentation Ethics

• RTEC 93
• Veinpuncture and Pharmacology for Radiologic
  Technologists

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ASRT

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

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American College of Radiology (ACR)

• Additional support for the administration of
  medications and venipuncture as part of the
  technologists scope of practice if found in the
  1987 Resolution No. 27

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Veinpuncture Laws

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

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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

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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.

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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.

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Four Elements to Prove Negligence

1. Must establish a duty to the patient by the
   health care provider
2. Breach of this duty by an act or by failing to
   perform some act.
3. A compensable injury
4. A causal relation between the injury and the
   breach of duty.

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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.

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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 patients permission, even
  if no injury arises from such contact.

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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.

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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.

13
Informed Consent

• A persons 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.

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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 patients consent commits
  an assault, for which he is liable in damages.

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Six functions of this Law

1. Protects individual autonomy
2. Protects the patients status as a human being
3. Avoids fraud and duress
4. Encourages health care practitioners to carefully
   consider their decisions
5. Fosters rational decision making by the patient,
   and
6. Involves the public in medicine

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The Health Record in Court

• The radiograph as evidence
• Dark/light radiograph
• Mis-marked films
• Wrong patient information

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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?

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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.

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

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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

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• 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

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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

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Documentation

• The five rights of medication administration is
  to be included in every patients 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.

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Document Meds Given

• 5 rights of medication administration
• The right patient
• The right medication
• The right route
• The right amount
• The right time

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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.

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Charting Exam Completion

• M.D.s order in patients 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)

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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
  patients health to have access or if the
  knowledge of the health care information could
  cause danger to the life or safety of any person.

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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.

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Documentation

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

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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

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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

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Ethical Analysis

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

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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

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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.

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Identifying the Problem

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

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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 patients family but also the
  health care professionals and administrators to
  whom they entrust their care.

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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

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Defending Your Selection

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

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Situation Judgment Tests SJTsI 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 didnt 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. Greens family. He is smiling and joking
  with them as he signs Mrs. Greens discharge
  papers. Shaken, you mutter to yourself, I think
  Dr. Jones misread the film. What should you do