Documents and Records:

 The amount and detail of information written in the documentation must reflect the exact
subjective, objective, assessment, and plan information for each patient. This is known as SAOP
note.
 Handwriting
 Proper use of grammar
 Proper use of formatting
 Confidentiality
 The health Insurance portability and accountability act was passed by the united states federal
government which allows patients to decide how their medical records are used and who has
access to them.

Patient’s Bill of Rights:

 The patient’s bill of rights is a list of rights that explains what health care a patient should
receive and how they should be treated under the medical care of professionals.
 Three major objectives of the patient’s bills of rights are:
To strengthen consumer confidence and promote self-advocacy of care by assuring the
health care system is fair and responsive to consumer’ needs.
To reaffirm the importance of strong relationships between patients and their
healthcare professionals.
To establish rights and responsibilities for all participants to promote the critical role of
consumer- centered care.
 High quality hospital care: Patients have the right to quality care and to know the identity of all
healthcare employees that will be treating them.
 Involvement in care: Patients have the right to be involved in all decisions regarding their care.
 A clean and safe environment: Patients have the right receive care in a clean and safe
environment that meets professional standards and requirements.
 Protection of privacy: Patients have the right to privacy regarding their diagnosis, treatment,
and medical history.
 Continuity of care: Patients have the right to share involvement with doctors regarding their
treatment plans, including available options when they leave the hospital.
 Help with bill and filing insurance claim: Patients have the right to know each specific charge
from the hospital, as well as what payment methods are available to cover those charges.
 HIPAA is a federal law that overrides state laws regarding the safety of medical information,
unless the state law has stricter regulations than HIPAA.
 PHI- Protected Health information, is any information in a medical record that can be used to
identify an individual and that was created, used, or disclosed while providing a healthcare
service, such as a diagnosis or treatment.
 PHU is personally identifiable information in medical records, including conversations between
doctors and nurses about treatment.
 PHI also includes billing information and any patient-identifiable information and any patient-
identifiable information in a health insurance information management system
 Examples of PHI:
  Billing information from your doctor
 Email to your doctor’s office about a medication or prescription you need
 Appointment scheduling note with your doctor’s office
 MRI scans
 Laboratory test results such as outcomes from blood, urine, or body tissue tests
 Phone records
 Health insurance information.
 HIPAA standard:
 Administrative: policies and procedures that clearly demonstrate how health entities
and organizations will comply with HIPAA.
Ex:
 Adoption of a written set of privacy procedures coordinated by a privacy officer.
 Clear restrictions on employee access to protected health information (PHI).
 Ongoing training programs regarding the handling of PHI.
 Physical: Controlling physical access to protect unauthorized access to protected data.
Ex:
 Network security for hardware and software.
 Controlling access to hardware and software with PHI.
 Monitoring access to PHI
 Policies to regulate workstation and data use.
 Technical: Controlling access to computer systems and communications containing PHI
over open networks.
Ex:
 Protecting PHI from intrusion
 Monitoring unauthorized changes or deletions of PHI
 Ensuring data integrity such as authentication of information
 Maintaining documentation of HIPAA practices to ensure legal compliance.

Advance Directives:

 An advance directive allows healthcare providers to know a person’s specific wishes in the event
they are incapacitated and unable to relay those wishes.
Living will: a document that lets people state their wishes for end-of-life medical care in
case they become unable to communicate their decisions. It has no power after death.
A living will must be signed when that person is fully aware of the decisions they are
making. There must be two adult witnesses who are not involved in any decisions that
can result from the living will.
Power of attorney: a legal document that assigns another person with the responsibility
of making decisions on their behalf if the patient is unable to do so due to their medical
conditions.
o Can range from using funds, receiving treatments or procedures, or deciding
whether the patient should be kept alive.
o For must be signed by the patient, the person who will gain legal
responsibilities for decisions, two adult witnesses, and in most states signatures
on this document must also be notarized by a notary.
 o The person who becomes responsible for making those decisions is known as
the designation of healthcare signature.
DNR (Do Not Resuscitate): A request to not have CPR (Cardiopulmonary resuscitation) if your
heart stops or if you stop breathing while you are in a medical facility. An out-of-hospital DNR is
for people who do not want to be resuscitates if they have problem at home or anywhere
outside of a medical facility.
Organ and tissue donation: Allow organs or body parts from a generally healthy person who has
died to be transplanted into people who need them.

Informed Consent:

 Implied consent: Your agreement is given by cooperating with a healthcare professional’s

instructions for routine procedures. Ex: EMTs performing CPR on you in order to save your life.
You are not in any condition t verbally agree to this or sign anything. Therefore, unless you have
signed a DNR, there is implied consent for EMT’s to proceed with life-saving action.
 Verbal Consent: Your agreement is given verbally for a treatment or procedure that does not
carry a significant risk. Ex: Agreeing to allow a doctor to listen you your chest and back with a
stethoscope. By confirming to your doctor that they have permission, you are applying verbal
consent.
 Written consent: Your agreement is given by signing a document for a treatment or procedure
that is complex or carries a higher risk. Ex: Agreeing to a surgical procedure after your doctor has
explained it to you, including risks and recovery time. To receive the surgery, you will need to
sign a form of written consent.