For this assignment you need to study chapters: 18,19,20,21, in your book and PowerPoint presentation, and answer the following questions:1-Describe the contents of medical records.2-Explain the importance of maintaining complete and accurate records.3-Describe the advantages and disadvantages of computerized records.4-Discuss the purpose and various titles of the Patient Protection and Affordable Care Act of 2010 (PPACA).5-Explain what can happen if a state fails to comply with the Patient Protection and Affordable Care Act of 2010 (PPACA)6-Define Insurance Policy7-Explain the elements and conditions of an insurance policy.8-Explain the various federal and state labor acts.9-Describe a patient’s rights during labor disputes.10-Discuss the types of discrimination that occur in the workplace.
Chapter 18
Medical Records
LEARNING OBJECTIVES
• Describe the contents of medical records.
• Explain the ownership and who can access a
patient’s medical record.
• Explain the importance of maintaining complete and
accurate records.
• Describe the advantages and disadvantages of
computerized records.
• Explain what is meant by the medical record
battleground.
• Describe why the medical record is important in legal
proceedings.
Medical Record
Means of Communication
• Documentation of a patient’s
– Illness
– Symptoms
– Diagnosis
– Treatment
• Planning tool for patient care
• Document communication (e.g., progress
notes)
Medical Record
Means of Communication – II
• Protect legal interests of patient, org, &
practitioner
• Provide database for use in statistical
reporting
• Continuing education
• Research
• Provide info necessary for 3rd-party billing
Managing Information: IM Plan
addresses
• Patient care information
• Flow of information
• Accuracy of information
• Timeliness
• Confidentiality
• uniformity of data collection and de?nitions
• third-party payer needs
• disaster plans for the recovery of information
• annual review of the plan
• managing change
Medical Record – I
Admission record
• Demographic Data
– Age
– Address
– Reason for admission, social security number
– Marital status
– Religion
– Health insurance
• Advance Directives
Medical Record – II
History
• Chief complaint
• History of present illness
• Past medical history
• Allergies
• Current Medications
• Social history
• Family history
• Reproductive History
Medical Record – III
Physical
• General appearance
• Vital signs
• Skin
• Lymph nodes
• HEENT
• Neck
• Thorax, Lungs
• Female & male breasts
• Cardiovascular
• Abdomen
• Genitalia
• Rectum
• Musculoskeletal
• Neurologic
• Assessments
– Problem list
Medical Record – V
Physical
• Consent Forms
• Assessments
– Physician H & P
– Nursing,
– functional,
– nutritional
– social
• Pain management
records
• Treatment plan
• Physicians’ orders
• Diagnostic reports
– laboratory
– imaging
• Consultation reports
Medical Record – VI
• Operative reports
– Post Op Note
– Surgery
• Anesthesia
–Assessment
–Administration
• Medication
administration records
• Pain management
records
• Progress notes
– Nursing notes
– Notations of other
disciplines
• Patient education
• Discharge planning
– social service notes &
reports
– medication use
instructions
– Physician follow-up
Ownership & Release of
Medical Records
• Ownership organization or professional
rendering treatment
Ownership & Release of Records
• Ownership
• Request by Patients
– Right to access
• Requests: 3rd Parties
– insurance carriers (for processing claims)
– medical research
– educators
– government agencies
Ownership & Release of Records:
Privacy Exception
• Psychiatric records
• Criminal investigations
• Medicaid fraud
• Substance abuse records
Retention of Records Varies
Among States
• In Illinois, the ILL. Supreme Ct. held that a
private cause of action existed under X-ray
retention act. The plaintiff stated claim under
the act, which provides that hospitals must
retain X-rays & other such photographs or
films as part of their regularly maintained
records for a period of 5 years.
– See text case: Rodgers v. St. Mary’s Hosp. of
Decatur
Electronic Records
Advantages – I
• Retrieve demographic information &
consultants’ reports, as well as lab, radiology,
& other test results
• Improve productivity & quality
• Reduce costs
• Support clinical research
Electronic Records
Advantages – II
• Play an ever-increasing role in education
• Allow for interactive computer-assisted
diagnosis & treatment
• Allow for computer-generated prescriptions
• Generate reminders for follow-up testing.
Electronic Records
Advantages – III
• Assist in the decision-making process.
• Aid in standardizing treatment protocols.
• Assist in the identification of drug-drug &
food-drug interactions.
• Used in telecommunications around the
world, transporting picture graphics (e.g.,
computed tomography scans) between
nations.
Computerized Medical Records
Disadvantages
• Increased risk of lost confidentiality
– unauthorized disclosure of information
• High-tech crime
– increases in cyber crime
• products & services to combat
cybercrime
– costs to protect networks & critical
infrastructures from cyber-based threats.
Medical Record Battleground
• Tampering
• Angry recordings
– registering complaints by other caregivers &
the org
• Rewriting & replacing notes
Text Cases
• Alteration of Records
• Objection to Record Notations
• Tampering with Record Entries
• Rewriting and Replacing Notes
• Fatal Handwriting Mix-Up
Confidential & Privileged Communication
• Breach of Physician-Patient Confidentiality
• Ordinary Business Documents
• Attorney-Client Privilege
HIPAA
Privacy Provision – I
• Patients able to access their record & request
correction of errors.
• Patients must be informed of how personal info
will be used.
• Patient consent for release of info for marketing
purposes required.
• Patients can ask insurers & providers to take
reasonable steps to ensure their communications
are confidential.
• Patients can file privacy-related complaints.
HIPAA
Privacy Provision – II
• Health insurers or providers document their privacy
procedures.
• Health insurers or providers designate a privacy
officer & train their employees.
• Providers may use patient info without patient
consent for
– purposes of providing treatment
– obtaining payment for services
– performing non-treatment operational tasks of
the provider’s business.
Charting & Helpful Advice – I
• Complete & pertinent entries
• Timely entries
• Legible entries
• Clear & meaningful entries
• Complete
Charting & Helpful Advice – II
• Avoid
– defensive & derogatory notes
– erasures & correction fluids
– criticism
– complaints
– tampering with the chart
Charting & Helpful Advice – III
• Secure records pending legal action
• Obtain legal advice
• Entries made by others must not be ignored.
– patient care is a collaborative
interdisciplinary team effort.
– Entries made by health care professionals
provide valuable information in treating the
patient.
REVIEW QUESTIONS – I
1. What are basic purposes of medical record?
2. Discuss advantages & disadvantages of
computer-generated medical records.
3. Medical record is sole property of the
hospital & should never be released. Discuss
your opinion on this statement.
4. How long should patient records be
maintained?
Chapter 19
National Health Insurance
& Managed Care
LEARNING OBJECTIVES
• Discuss the purpose and various titles of the
Patient Protection and Affordable Care Act of
2010 (PPACA).
• Discuss the Supreme Court’s ruling on the
constitutionality of the PPACA.
• Describe the common models of managed care
organizations.
• Explain what can happen if a state fails to comply
with the PPACA.
PPACA Purpose
• Increase # of Americans covered by health
insurance
• Decrease cost of insurance
– Make more affordable through shared
responsibility
• Eliminate discriminatory acts
– Exclusion due to pre-existing conditions,
health status, & gender.
PPACA Reforms Health Care – I
• Eliminate lifetime & unreasonable annual limits on
benefits
• Prohibit recessions of health insurance policies
• Assistance for uninsured due to pre-existing
conditions
• Require coverage: preventative services &
immunizations
• Extend dependent coverage up to age 26
PPACA Reforms Health Care – II
• Develop uniform coverage documents so consumers
can make equal insurance comparisons
• Cap insurance company
– nonmedical & administrative expenditures
• Ensure consumers have access to an effective
appeals process
– provide a place to turn for help
• navigating the appeals process & assessing
coverage
Supreme Court 6/28/12
• Agreed that the requirement for nearly all
Americans to buy health insurance.
• Court excised part of law requiring states to
expand their Medicaid coverage in a joint
federal–state effort, to families with incomes
up to 133% of the Federal Poverty Level (FPL).
PPACA Titles
Title I. Quality Affordable Health Care for All
Americans
Title II. The Role of Public Programs
Title III. Improving the Quality and Efficiency of
Health Care
Title IV. Prevention of Chronic Disease and
Improving Public Health
Title V. Health Care Workforce
PPACA Titles – II
Title VI. Transparency and Program Integrity
Title VII. Improving Access to Innovative Medical
Therapies
Title VIII. CLASS Act
Title IX. Revenue Provisions
Title IX. Strengthening Quality, Affordable
Health Care for All Americans
Models of Managed Care
Organizations (MCO’s)
• Health Maintenance Organizations
• Preferred Provider Organizations
• Exclusive Provider Organizations
• Point of Service Plans
• Experience-Rated HMOs
• Specialty HMO’s
• Independent Practice Associations
• Physician Group Practice
Models of MCOs – II
• Group Practice without Walls
• Physician-Hospital Organizations
• Medical Foundations
• Managed Service Organizations
• Vertically Integrated Delivery System
• Horizontal Consolidations
• Federally Qualified
Federally Qualified MCOs
• Strictly Voluntary
• Must Meet Federal Standards
• Less flexibility in
– benefits packages
– setting premium rates
• Must Provide Basic Package of Health Services
State HMO Laws – I
• Specify what types on entities may operate an
MCO.
• Require the provision of basic care services
– ED
– Inpatient care
– Physician care
– Outpatient care
State Laws – II
• Generally require
– continued coverage if enrollee’s health
status changes
– ability of enrollee to convert to a direct
payment plan
– grievance procedure for enrollees
Case Management Firms
• Assist employers & insurers in managing in
managing catastrophic cases.
• Negotiate services & reimbursement with
provider’s who treat patient’s condition.
• Develop a treatment protocol & monitor
treatment.
Third Party Administrators (TPAs)
• Provides services for employers & associations
that have group insurance policies.
• Acts as a liaison between employer & insurer.
• Provides administrative activities
– Claims processing
– Certifying eligibility
– Preparation of reports
Utilization Review
• 3rd party evaluates medical necessity of care
• Process of Reviews of patient care conducted either
by
– Prospective Review
– Concurrent Review
– Retrospective Review
• Utilization Management Firms
– perform utilization management activities for
managed care entities, insurers, or employers
Liability for Nonemployee Participating
Physicians
• Patient must reasonably view the entity & not
the physician as the source of care.
• Patient reasonably believes the physician to
be an employee of the entity.
Employee Retirement
Income Security Act
• Designed to ensure employee welfare & benefit
plans conform to a uniform body of benefits law.
• Requires plans to provide participants with plan
information.
• Requires fiduciary responsibilities for those who
manage & control plan assets.
• Establish appeals & grievance process.
• Provide participants with rights to to sue for
benefits & breaches of fiduciary responsibility.
Health Care Quality
Improvement Act of 1986
• The purpose of the HCQIA is to provide those
persons providing information to professional review
bodies & those assisting in review activities limited
immunity from damages that may result as a result
of adverse decisions that affect a physician’s medical
staff privileges.
• Immunity does not extend to
– civil rights litigation suits.
– suits filed by U.S. Attorney General.
Managed Care & Legal Actions – I
• Open enrollment
• Emergency Care
• Market Power
• Product Market
• Geographic Market
• Ethics and the Denial of Services
Review Questions
1. Describe some of the more common models
of MCOs.
2. What are the advantages and disadvantages
of HMOs?
3. What is the purpose of utilization review?
4. Discuss the various reforms included in the
Patient Protection and Affordable Care Act.
Chapter 20
Professional Liability Insurance
LEARNING OBJECTIVES
• Describe the purpose of an insurance policy
including risk categories and the importance
of professionals to carry professional liability
insurance.
• Explain the elements and conditions of an
insurance policy.
• Describe the investigation and settlement of
claims.
Insurance Policy
• Insurance is a contract that creates legal
obligations on the part of both the insured
and insurer.
– Insurer agrees to assume certain risks of the
insured for consideration or payment of a
premium.
• Insurer promises to pay specific amount of
money if specified event takes place.
Liability Insurance
• Purpose of liability insurance is to spread risk
of economic loss among members of a group
who share common risks.
• As risks increase, premiums increase to cover
associated risks.
• Premiums are placed in shared risk fund
– funds are drawn to cover costs of lawsuits.
Elements of Insurance Policy
1. Identification of Risk Covered
2. Specific Amount Payable
3. Specified Occurrence
Risk Categories
1. Property loss or damage
2. Personal injury
1. illness
2. accident
3. Liability
1. professional
Insurance: Policy Types
1. Occurrence
2. Claims-made
3. Tail coverage
4. Umbrella
Uninsured Claims
• Intentional Torts
• Criminal Acts
– Child Abuse
– Senior Abuse
– Sexual Assaults
• Fraud
Review Case:
Sexual Assault
1. Does sexual assault generally constitute
rendering professional services within the
coverage provisions of a physician’s insurance
policy?
2. Should a malpractice insurer be required to
indemnify a physician for liability resulting
from the sexual assault of a minor?
NO!!!
• Sexual assault does not constitute rendering
professional services within coverage
provisions of a physician’s insurance policy.
• The Supreme Court of Nebraska in R.W. v.
Schrein held that sexual assault does not
constitute rendering professional service.
– Five patients claimed they were sexually
assaulted during examination & treatment.
Insurance Policy Conditions
• Notice of Occurrence
• Notice of Claim
• Cooperation of the insured
• Co-insurance
• Assignment
• Subrogation
• Cancellation
Liability of the Professional – I
• Need for Insurance: All professionals
– allied health professionals
• insurance relatively inexpensive
• Protect yourself
– Don’t practice without insurance
– Prepare for the worst scenario; have no regrets
– Seldom occurrence, but employer could seek
recovery of losses from negligent employee
Liability of the Professional – II
• Volunteer at a clinic or health fair not
sponsored by his or her employer
• Independent contractor providing a service in
a patient’s home
• Worker for an independent agency or registry
Medical Liability Insurance
• Coverage
– Malpractice
– Acts or omissions in care
– Coverage varies company to company
Self- Insurance
• Against malpractice risks
– due to high costs of primary coverage
– actuary to determine the proper level of funding
• Purchase excess coverage
Protecting the Organization
• Self-insurance
• Trustee coverage
• Mandated medical staff insurance coverage
• Investigation & settlement of claims
Investigation and Settlement
• Duty of insurer to defend insured
• Insurer can settle claims
• Plaintiff/s sign a general release upon
settlement
REVIEW QUESTIONS – I
1. Describe the elements of an insurance policy
2. Describe the conditions of an insurance policy as
described in this chapter.
3. Under what circumstances do you think a health
care professional be self-insured?
4. Why do insurance carriers require “timely”
notice of a claim?
5. Describe what occurrences an insurance policy
does not cover.
Chapter 21
Labor Relations
LEARNING OBJECTIVES
• Explain the various federal and state labor acts.
• Discuss the rights and responsibilities of unions
and management.
• Describe the purpose of an “Affirmative Action
Plan.”
• Describe a patient’s rights during labor disputes.
• Discuss the types of discrimination that occur in
the workplace.
Federal & State Labor Laws
• Relationships between employees &
employers are regulated by state & federal
laws.
• Federal laws generally take precedence over
state laws when there is conflict between
state & federal laws.
• State laws generally applicable when more
rigid than federal laws.
U.S. Department of Labor
• Cabinet level department
• Functions
– promote welfare of wage earners
– improve working conditions
– advance opportunities for profitable
employment
National Labor Relations Act – I
• Enacted 1935 to govern labor-management
relations of business firms engaged in
interstate commerce.
• Act defines certain conduct of employers &
employees as unfair labor practices
– provides for hearings on complaints that
such practices have occurred.
National Labor Relations Act – II
• Act modified by
– Taft-Hartley amendments of 1947
– Landrum-Griffin amendments of 1959
National Labor Relations Board – I
• NLRB enforces & administers the NLRA
– has jurisdiction over matters involving
proprietary & not-for-profit health care
organizations.
– agency independent of department of
labor, that is responsible for preventing &
remedying unfair labor practices by
employers & labor organizations.
National Labor Relations Board – II
• Unions & Healthcare Orgs
– Through mid-1930s, little union organizational
• slow growth until late 1950s.
– Union activity successful in geographic areas in
which unions have been active in other industries
– Limitations on # of bargaining units
• employees can form up to 8 bargaining units
• upheld by U.S. Supreme Ct.
National Labor Relations Board – III
• Elections
– NLRA sets out procedures by which
employees may select a union as their
collective bargaining representative to
negotiate employment and contract matters.
• Unfair Labor Practices
– Unlawful Interrogation
– Failure to Discharge Non-Dues Paying Nurses
Norris-LaGuardia Act
• Aimed at reducing number of injunctions to
restrain strikes & picketing.
• Sets procedures for handling labor disputes.
• Creates board of inquiry if a dispute threatens
to interrupt health care.
• Board’s findings provide framework for
arbitrators’ decisions.
Labor-Management
Reporting & Disclosure Act
• Places controls on labor unions &
relationships between unions & membership.
• Requires employers to report payments to
representatives of labor orgs.
• Expenditures made to influence way
employees exercise rights.
• Disclosure of agreements with labor
consultants.
Fair Labor Standards Act
• Establishes
– minimum wages
– maximum hours of employment
– overtime pay provisions
– exempt employees provisions
– work week options
Civil Rights Act of 1964
• Prohibits private employers & state & local
governments from discrimination in
employment in any business on basis of:
– race,
– color,
– religion,
– sex, or
– national origin.
OSHA – I
• Sets & enforces safety standards
• Provides training, outreach, & education
• Establishes partnerships
• Encourages continual improvement in
workplace safety & health
OSHA – II
• Promulgation & Enforcement of OSHA
Standards
• Recordkeeping
• Education
• Infectious Body Fluids
• Employee Complaints
• State Regulation
• Legal Liability
Rehabilitation Act of 1973
• Protection for handicapped employees
• Applied to public & private orgs
• Requirement to perform self-evaluation of
compliance
• Jobs must not be designed to eliminate hiring
of disabled persons
Family and Medical Leave Act – I
• Enacted to grant employees temporary
medical leave under certain circumstances.
• Covered employers must grant eligible
employees up to a total of 12 workweeks of
unpaid leave during any 12-month period.
Family and Medical Leave Act – II
• Leave granted for:
– birth & care of employee’s child.
– placement of adopted or foster child with
employee.
– care of immediate family member (spouse,
child, or parent) with a serious health
condition.
– inability to work because of serious health
condition.
Family and Medical Leave Act – III
• Illegal to terminate health insurance coverage
for an employee on FMLA leave.
• Following FMLA leave, employee’s job—or an
equivalent job with equivalent pay, benefits, &
other terms & conditions of employment—
must be restored.
State Labor Laws – I
• Laws Vary State to State
– Union Security Contracts and Right-to-Work
Laws
– Wage and Hour Laws
State Labor Laws – Union Security
Contracts
• Closed shop contract
• Union shop contract
• Some state statutes forbid such contracts
• Right-to-work laws
• Wage & hour laws
State Labor Laws – III
• Child Labor Acts
– working papers
– forbids employment of minors at night
– prohibits minors from operating certain
machinery
• Workers’ Compensation
– physical injury
– job stress
– influenza Vaccination
Labor Rights
• Organize & bargain collectively
• Solicit & distribute union info
• Picket
• Strike
Management Rights
• Receive a strike notice
• Hire replacement workers
• Restrict union activity
• Prohibit union activity during working hrs
• Prohibit supervisors from participating union
activity
Patient Rights & labor Disputes
• Patient rights take precedence over labormanagement rights
• Patients have right to
– privacy
– well-being
Affirmative Action Plan – I
• Prohibits discrimination on basis of age, race,
color, religion, sex, national origin.
• Affirmative action program includes
– collection & analysis of data on the race and
sex of all applicants for employment.
– non-discrimination clause in manuals.
– use of data to show compliance with the
law.
Affirmative Action Plan – II
• Failure to comply can result in denial of
federal funds.
• Health care orgs should have equal
employment opportunity or affirmative action
plan in place.
Injunctions
• Court order directing that a certain act be
performed or not performed.
– Persons who fail to comply with court
orders are said to be in contempt of court.
• Earliest use of injunctions in labor relations
was by employers to stop strikes or picketing
by employees.
• Availability of injunctive relief limited.
Administering
Collective Bargaining Agreement
• Administered in “good faith”
• Supervisors should familiarize themselves with
the agreement
• Importance of recordkeeping
• Grievance procedures
• Arbitration
Workplace Discrimination – Age
• Discrimination in Employment Act
• Promotes employment of older persons
• Prima facie case
1.complainant is in a protected age group
2.complainant is quali?ed for his or her job
3.complainant was discharged
4.discharge occurred in circumstances that give rise
to inference of age discrimination
Workplace Discrimination – Disability
• Americans with Disabilities Act
– enacted by Congress to prohibit age
discrimination
• Tips for Employers
– train managers as to ADA requirements
– review & revise job descriptions for compliance
– bring physical environment into compliance
– post notice describing purpose of ADA
Workplace Discrimination – III
• National Origin
• Pay Discrimination
• Pregnancy Discrimination
• Race
• Religion
• Sex
Sexual Harassment
• Unwelcomed sexual advance
• Request for sexual favors
• Verbal or physical conduct of a sexual nature
• Creating an environment that is unreasonably
intimidating or offensive
Preventing Sexual Harassment
• Implement an anti-harassment policy.
• Prompt action to prevent & correct any
harassment.
• Encourage employees to promptly report
harassment.
REVIEW QUESTIONS – I
1. Provide a general overview of the NLRA.
2. Using the hospital as a setting, give two
examples of what would violate the NLRA.
3. How do patients’ rights come into play during
a strike by nurses?
4. What is the purpose of OSHA?
REVIEW QUESTIONS – II
5. Why was the Norris-LaGuardia Act enacted by
Congress?
6. Discuss various ways in which discrimination
can occur in the workplace.
7. What steps can an organization take to
prevent successful lawsuit brought forward on
the basis of sexual harassment.

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