. LEGAL CONCEPTS
Informed Consent163
Legal Restrictions164
Contracts165
Professional Credentialing167
Negligence and Malpractice167
Risk Management168
CONFIDENTIALITY
In the course of treatment, all learned information about a patient is confidential. In order for you to share confidential information with others who are not involved in direct care (e.g., other physicians to whom your office refers the patient, the physician who referred the patient to your office, insurance providers), the patient must provide written consent.
• Never release any information to family, friends, or others who call except to the parents of minor children who are patients.
• Never gossip about patients. If it is necessary to discuss a patient with another staff member, do so in a private place.
Inappropriate release of information about a patient is an invasion of privacy, in addition to being illegal. Every medical office has forms that patients must sign to provide consent for sharing medical information with others who need to know.
Patient confidentiality got a large boost in the new millenium with the passage of the Health Insurance Portability and Accountability Act (HIPAA). Under HIPAA, the following rights are safeguarded:
• Patients are guaranteed access to their medical records.
• Strict limits are placed on how medical information can be used in marketing efforts by pharmacies, medical service providers, or producers of medical devices or pharmaceuticals.
• Patients are guaranteed to receive confidential communications. A patient may request that only he or she receive any communications about treatment (i.e., communicate through place of work, not home).
• Formal mechanism for complaints about privacy practices or implementation of HIPAA directives by any entity falls under HIPAA regulations.
The one general exception regarding patient privacy lies in the area of mandated public health or other reports. Mandated reports include the following:
• Vital statistics (e.g., births, deaths)
• Communicable diseases such as tuberculosis and HIV
• Adverse reaction to vaccines
• Injuries caused by lethal weapons (e.g., gunshot wounds, stab wounds)
• Suspected abuse (e.g., child, spouse, elder)
Your role in balancing patient confidentiality with requirements for reporting is paramount. Remember, in many instances you are the first point of contact with a patient, as well as the person who will have the most contact with a patient. In many ways, you are the liaison between the patient and the licensed care providers in the office. You need to communicate effectively within the bounds of legal requirements.
Certain diseases must be reported to the local boards of health, suspected abuse must be reported to the proper state authorities, births and deaths must be reported, and injuries that may be the result of a crime must be reported to the local police department.
INFORMED CONSENT
Before performing any invasive procedure on a patient, the patient must give informed consent. A patient has the legal right to know and completely understand what will be done to or for him or her.
Before any procedure, the patient must be given a thorough explanation and reason for performing the procedure. For simple procedures such as an injection (other than immunizations), verbal consent is sufficient. For more extensive procedures such as minor surgery or endoscopy, the patient should sign a written consent form, which states that the procedure has been explained to the patient and that the patient understands the nature of and the reason for the procedure. Written consent is also required for human immunodeficiency viral (HIV) testing. Written consent is needed by parents to provide immunizations for their children.
The person performing the procedure is responsible for explaining it to the patient. In the medical office, the medical assistant (MA) is often the person who obtains written consent from the patient and witnesses the signing of the form. The form must be signed before any medication is administered that can alter the patient’s mood or thinking process. If the patient does not appear to understand or still has questions about the procedure, be sure that the physician or other provider speaks with the patient before obtaining the signature. Avoid making any promises about the outcome of the procedure while obtaining written consent. If the patient appears to be very concerned, refer him or her to the person (provider) who will perform the procedure.
LEGAL RESTRICTIONS
As an MA, consider the following four general legal restrictions:
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• You cannot perform activities that are part of the practice of medicine.
♦ Do not use diagnostic terms when documenting activities in the medical record.
♦ Ensure that a physician authorizes all prescription refills before contacting a pharmacy.
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