Term
List 5 reasons why it's important to document patient info |
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Definition
- facilitates positive patient outcomes with accurate, objective description of ongoing care.
- provides source for relevant patient info
- communication tool between H.P.
- research purposes
- doc evidence in legal proceedings
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Term
| Name 5 requirements when documenting patient information |
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Definition
- info must b clear, concise and accurate (McCabe v Auburn District Hospital)
- timing of documentation (Locher v Turner)
- If no doc then crt assumes it didn't happen (Jarvis v St Charles Medical Centre)
- Notes to have date and time
- Person making notes must sign & state position
- notes to be objective, legible and no personal comments
- Never write notes in advance and never someone elses.
- draw lines through errors and initial
- Draw line to end of page if blank
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Term
Name implications when health info is poorly recorded |
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Definition
- liability involving action in negligence against H.P. for carelessnes re: diagnosis, t'ment or giving info to patient when there's none to prove.
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Term
| Discuss the impact of electronic health records to Health Professionals |
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Definition
- Issues of confidentiality of info and protection of privacy are major concerns.
- H.P. responsible for recording info must and never disclose their pin number. Log out when completed records.
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Term
| List 5 strategies for protecting information |
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Definition
- Restricted access to certain providers
- Consent for use of de-identified data
- Rules for proxy consent
- Limit linkages
- Info needs to be stored and transmitted so not stolen or intercepted.
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Term
| List legislative provisions that protect confidentiality of patient info. |
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Definition
- Privacy Act
- Health Services Act
- Guardianship & Administration Act
- Transplantation & Anatomy Act
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Term
| List 2 Common Law decisions |
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Definition
- Negligence (Furniss v Fitchett)
- Breach of contract
- Equity
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Term
| List 3 Ethical Principles |
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Definition
- AMA Code of Ethics - keep info confidential re: patient and from colleages and divulge it only with patient's permission.
- ANMC Code of Ethics
- ANMC Code of Conduct
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Term
| Identify legal actions available when H.P breaches obligation to keep patient info confidential. |
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Definition
Statutory Breach - Privacy Act
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encourage internal complaint handling
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conciliation
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formal determination by Privacy Commissioner
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Enforcement in Federal crt.
Common Law
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Term
| Identify situations where an exception to obligation to keep info confidential |
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Definition
Consent
Legislation compelling disclosure
Freedom of Information
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1982 - Sec 11 - right of access
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sec 41 - docs affecting personal privacy
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1992 - sec 21 - right of access
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sec 44 - matter affecting personal affairs
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Term
| End of Life Decisions: Ethics and Law |
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Definition
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Term
| In Queensland, the statutory definition of death is contained in which Act. What is the definition? |
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Definition
Transplantation & Anatomy Act
Irreversible cessation of all functions of person's brain; or
Irreversible cessation of circulation of blood in person's body |
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Term
| Explain the role of an Advanced Health Directive |
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Definition
Powers of Attorney Act 1999
- allows adults with sound mind to direct in advance what they want done when no longer competent to decide.
- only has legal effect during period patient is incompetent.
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Term
| In the situation to withdraw or withhold special life sustaining measures the direction only applies in what circumstances |
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Definition
- patient has terminal illness that is irreversible & 2 doctors have same opinion that patient will die within 1 year.
- patient in persistent vegetative state
- patient permanently unconscious and no prospect of regaining consciousness
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Term
| Why is there a Statutory definition of death for situations where decisions need to be made to disconect life support? |
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Definition
| clear diagnosis needs to be made b4 switching off life suport. Some disorders places patients in vegetative state but section of brain regulating resp and cardiac functions still working and definition state "all brain function cessation" |
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Term
| Differentiate between Active, Passive, Voluntary and Involuntary Euthanasia |
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Definition
Active - pts wish to die (physician assisted)
Passive - active t'ment ceased/withdrawn from pt to allow death
Voluntary - pts having legal capacity and can make own decisions re: t'ment and whether or not to refuse certain t'ment
Involuntary - pt don't have legal capacity or not able to make t'ment decisions e.g. children
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Term
| What is a "Not for Resuscitation" order |
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Definition
- MO's right to order t'ment/non t'ment
- viewed as requiring pt's consent just like other forms of t'ment/non t'ment
- follow hospital policy/guidelines
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Term
| List 5 essential elements of murder as dictated by Qld Criminal Code |
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Definition
- act of killing (actus reus)
- malice of aforethought (mens rea)
- sound memory & age
- unlawfully kills
- victim must be reasonable creature in being
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