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Nursing and the Law
In the context of healthcare, information management can be described as the maintenance of records containing the confidential data of patients and medical workers.
A medical record should contain information related to a patient’s diagnosis, symptoms, and that the treatment that he/she received (Pozgar, 2011, p. 255). These data should be used by physicians and medical workers while choosing a treatment option that can best suit a patient.
The main advantage of computer-generated medical records is that they can be quickly accessed by a physician. Moreover, they can be easily transferred from one hospital to another. In turn, the main disadvantage is that the confidential data of patients can become available to unauthorized third-parties. It is the main risk that should be addressed.
In my opinion, there are situations when the medical record of a patient should be released. In particular, one can speak about those cases when an individual requires urgent medical assistance.
Peer-review information generated by medical organizations is protected because the release of these records can result in the disclosure of confidential information. Furthermore, this release can give rise to various lawsuits that can be filed against a medical institution.
In my view, the statements given by a defendant to the peer-review committee should be discoverable by a plaintiff in two cases. This information can help a person to protect his/her rights in this court. However, there are two important requirements. First of all, this information should be relevant to the case. Secondly, these records should be accessed only if the necessary data cannot be found in other documents.
Some parts of peer-review documentation should be protected. In particular, one should focus on the sections that can throw light on policy-making within this institution or the analysis of organizational problems. This protection is necessary to safeguard a hospital against possible legal liabilities and lawsuits (Pozgar, 2011, p. 271).
8) The court does not protect the information which can be gathered before a physician applies for staff privileges (Pozgar, 2011, p. 271).
9) Patient’s records should be maintained during the period within which a lawsuit can file against the organization. So, they should be kept at least for fifteen years. However, hospitals prefer to stores this information for a longer period.
Hospital Departments and Allied Professionals
An attending physician is responsible for reviewing the benefits and alternatives of various diagnostic tests or treatment options.
To secure the informed consent of a patient, a physician should fully discuss the benefits and risks of a certain medical procedure (Pozgar, 2011, p. 278). Moreover, a medical worker should explain why this procedure has been selected, among others.
It is important to obtain informed consent because, in this way, physicians and medical organizations can safeguard themselves against lawsuits for malpractices.
Yes, a patient can withdraw its consent even when the medical procedure is performed. However, he/she cannot do it if the termination of a medical procedure can endanger his/her life or health.
A parent cannot deny consent to the lifesaving medical procedure that can save the life of his/her child.
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From an objective viewpoint, informed consent can be attained if a physician fully describes the advantages and disadvantages of a diagnostic test or treatment method. Moreover, a physician should speak about the probability of success (Pozgar, 2011, p. 286). However, one should not forget about the subjective experiences of a patient, such as the mental stress that he/she can struggle with.
It is critical to remember that in the majority of cases, patients are not learned in medical science. Therefore, a physician should give detailed explanations while speaking about various diagnostic tests or treatment options.
Information Management and Patient Records
Child abuse can be defined as the intentional mental, sexual, or physical injury which can be inflicted either by a parent or other person who is responsible for the wellbeing of a child (Pozgar, 2011, p. 206).
Medical workers, educators, and psychologists are obliged to report child abuse if they see signs of possible injuries.
There are various signs of elder abuse; one should pay close attention to such indicators as unexplained scars or bruises, dislocations, broken eyeglasses, and many others. Moreover, a caregiver, who does not allow medical or social workers to see the elder person, can also be suspected of inflicting a physical or emotional injury.
The Health Care Quality Improvement Act was adopted to protect the rights of patients. Before the inaction of this law, physicians could easily move from one state to another without having to disclose their malpractice payments. However, they could threaten the life and health of many other patients. In turn, this legal action was aimed at fostering peer-review in medical organizations.
The National Practitioner Data Bank was established to improve the quality of healthcare. This database stores information about possible malpractices of physicians. This information can be accessed by hospital administrators.
A sentinel event is an unexpected death or permanent injury that cannot be explained by a patient’s illness (Pozgar, 2011, p. 306).
The Root cause analysis is a chronological review of a certain unexpected and unwanted event. While working on this task, hospital administrators and physicians should identify when, how, and why a certain event took place (Pozgar, 2011).
There are several elements of a corporate compliance program. Secondly, it should contain the mechanism for the identification of possible malpractices. Secondly, this program should ensure that hospital administrators can prevent such pitfalls.
Pozgar, G. (2011). Legal Aspects of Health Care Administration. New York, NY: Jones & Bartlett Publishers.