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Intro RC Exam 3 Ethics,Charting & EMR With
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What sanctions can apply when a licensed health provider breaks the law?
- Reparations or fines
- Incarceration
- Licensure suspension
What simple question does ethics attempt to answer? How should we act?
What ethical issue has recently become a significant concern for respiratory therapists and all health care providers due to a congressional act? Patient's right to privacy
Which ethical principle obliges a respiratory therapist to uphold a patient's right to refuse a treatment? Autonomy
We have an expert-written solution to this problem! A health professional who withholds the truth from a patient, saying it is for his or her own good, is engaged in what practice?
Benevolent deception
The debate over prolongation of life versus relief of suffering in elderly patients mainly involves differing opinions regarding what ethical principle? Autonomy
We have an expert-written solution to this problem! What is the term for a civil wrong committed against an individual or property, for which a court provides a remedy in the form of damages? Tort
What is necessary to validate a claim of professional negligence?
- The practitioner owed a duty to the patient.
- The practitioner was derelict with that duty.
- The breach of duty was the direct cause of damages.
A respiratory therapist who engages in a questionable business practice is committing what type of malpractice? Ethical
When a practitioner performs a procedure that involves physical contact without the patient's consent, it can result in what charge? Battery
What are legitimate defenses against an intentional tort?
- Lack of intent to harm the patient
- Informed consent given by patient
A physician specifies an incorrect dose in a prescription for a powerful bronchodilator drug to be given to an asthmatic patient. When the respiratory therapist gives the prescribed dose, the patient suffers a fatal response and dies. Based on the principle of duty, against whom could a suit of negligence be brought?
- Respiratory therapist
- Attending physician
- Dispensing pharmacist
Which of the following are considered intentional torts?
- Assault and battery
- Defamation of character
- Invasion of privacy
A clinician who justifies support for withdrawing life support from a patient because "in the end, it would be best for all involved" is applying what ethical viewpoint? Consequentialism
Why is EMR essential in modern healthcare? Real-time Access: Immediate, secure access to patient information.
Better Communication: Improves communication across healthcare teams. Error Reduction: Minimizes errors due to illegibility or incomplete records. Data Analytics: Facilitates data-driven decisions for better patient outcomes. Patient Safety: Supports clinical decisions by providing alerts and reminders.
What are the regulations that govern EMR use? HITECH Act: Encourages the adoption of EMRs and enforces meaningful use standards. CMS Guidelines: Centers for Medicare & Medicaid Services require proper EMR use for billing and reimbursement. Joint Commission Standards: Healthcare facilities must meet certain documentation standards.
What are the penalties for non-compliance? Monetary Fines: HITECH Act includes penalties for not using EMRs in a compliant manner. Legal Consequences: Inaccurate documentation or misuse of EMR can lead to lawsuits. Loss of License or Accreditation: Severe violations could result in disciplinary actions.
What are the key responsibilities of RTs in using EMR systems? Acknowledging Physician Orders: Ensuring orders are acknowledged in a timely and accurate manner. Checking Orders for Accuracy: Validating treatments such as ventilator settings, oxygen prescriptions, and medication orders. Documenting Treatments & Interventions: Inputting data related to respiratory care interventions and patient responses. Monitoring Patient Progress: Recording data such as oxygen saturation, blood gas
Why is it important to check orders? Patient Safety: Ensures that treatments are appropriate and safe based on patient condition. Avoiding Errors: Cross-checking orders prevents medication errors, incorrect ventilator settings, or inappropriate treatments
What are the verification steps?
- Patient History Check: Review the patient's condition and recent interventions.
- Double-check the Order: Verify that the prescribed intervention matches the clinical need.
- Communicate: If something seems incorrect or unclear, discuss with the ordering physician or other team members.
Understanding Verbal and Telephone Orders: Verbal Orders: Given directly by the physician but must be documented immediately by the RT. Telephone Orders: Given over the phone and must also be accurately documented.
Legal Requirements: Timely Documentation: Document the verbal/telephone order in the EMR as soon as it is given. Physician Signature: Ensure the physician signs the order within the required timeframe (usually 24-48 hours). Hospital Protocols: Always follow institutional policies on verbal and telephone orders.
RT's Role in Verbal and Telephone Orders:
Accuracy is Key: Ensure precise transcription of the order into the EMR. Follow-up for Confirmation: Contact the physician for confirmation if any part of the order is unclear or potentially unsafe.
What is HIPAA? The Health Insurance Portability and Accountability Act establishes national standards for protecting sensitive patient data.
What is PHI? Protected Health Information: includes any information that can identify a patient (e.g., name, medical records, social security number, etc.)
What is the RT's role in HIPAA and PHI? Only access patient records directly related to the care they are providing. Avoid unnecessary disclosure of PHI in verbal or written form. Ensure PHI is securely stored in the EMR and not shared outside of authorized channels.
What are the consequences of HIPAA violations? Fines: Civil penalties can range from $100 to $50,000 per violation. Criminal Charges: Severe violations may result in criminal prosecution. Reputation Damage: HIPAA violations can harm the RT's reputation and that of the healthcare facility.
Best practices for respiratory therapists?
Physician charting •Writes all orders (including respiratory therapy) •Documents history and physical exams •Reviews all data to formulate a diagnosis
- Document daily progress. •Documents surgeries or procedures performed
Nurse charting •Charts daily notes about the ongoing care of that patient •Records laboratory data and medications given
RT Charting •Documents all therapy given to that patient as well as the progress of the respiratory status. •Records Ventilator checks, treatments, and how well the patient tolerated the treatment.
Physician progress note •This is a record of daily progress •All staff taking care of the patient can refer to these notes for updated progress •May include notes from all physician services •Includes the SOAP notes
SOAP
•Subjective— Data that is supplied by the Patient. •Objective -Data that the therapist gathers through observations, x-ray interpretations, or test results. •Assessment -A description of the nature and severity of the patient's symptoms and condition. This section includes both subjective and objective data. •Plan -Developed by the physician and therapist. The plan should specify type, frequency, and duration of therapy. Additionally, a reassessment date should be included to evaluate the effectiveness of the therapy.
Patient history includes? •Admitting problem •History of illness -when did it start
- Past medical history-past surgeries or illness •Family history -Heart disease or Stroke •Social history -smokes or drinks, any hx. Of drug use
Standing orders: RT protocols •Any set of orders prewritten (usually typed) •For example: a post -op open heart surgery has routine standing orders for all patients..
Respiratory care orders: •Needs a date and time written •Should be clear, concise and legible •Include treatment to be given(IS, updraft, CPT) •Frequency ( Q2, Q4, QID....)
•To aid the physician in making a correct diagnosis. •To show daily progress of the patient •To provide material for research •To be used, if necessary, as legal evidence in court.
Standard abbreviations in hospitals •BID bis in die (twice daily) •CPT Chest physiotherapy •CTA clear to auscultation •DC discontinue
- FiO2 fractional concentration of inspired oxygen •IS incentive spirometry
Standard abbreviations in hospitals (cont) •LPM liters per minute •mp mouth piece •ml milliliter = cc •NPO nothing by mouth •s without •SOB shortness of breath •USN ultrasonic nebulizer •Vt tidal volume •WNL within normal limits
General Charting Rules •If therapy is missed, chat that the treatment was not given. (PNA, TNA) •Record the date and time for every entry. •Always sign you entries with the first initial of your first name, your last name, and credentials. •Use the chart for charting therapy and gaining information about your patient. Remember that the information in the chart is confidential. •Try to chart therapy immediately after it has been given, never never before. •Provide clear, concise, and accurate statements. •Never chart in such a way as to give the impression you are diagnosing or making a medical conclusion.
