Medical malpractice is a very serious offense because it constitutes a breach of trust in the patient-doctor relationship and it causes severe consequences to the victim's life. Doctors, nurses, paramedics, allied health technicians, and medical assistants alike are expected to do everything they can to promote patient health and healing, and not to cause harm
Medical record documentation is an essential component in the care of the patient and protecting the medical staff in the case of legal action. While many medical office staff members will admit that medical documentation is important, many also complain about the lack of time to document. Documentation serves some very useful purposes:
1. As a form of communication by and between the team members caring for the patient, This includes the direct and non-direct caregivers, and the physicians.
2. As a permanent record of the events surrounding the care of the patient and the patient's response to the care.
3. For reimbursement purposes (payment by insurance companies).
4. To CYOA (Cover Your Own Anatomy).
The medical record is a legal document and should be treated as such. In the event of a lawsuit, lawyers, judges, jurors and medical experts hired by the plaintiff's attorney will review the records. The purpose of their review is to prove the allegations of medical negligence. So remember what are called the Six C's of Documentation: Documentation should be contemporaneous, complete, concise, comprehensive, clear and correct.
Although Medical Assistants are none licensed healthcare providers who work under the direct supervision of the physician and the physician is responsible for their actions, this does not exonerate them from risk of direct liability. Each healthcare practitioner is responsible for his or her own negligent acts, since malpractice is defined as "the negligent act of a person with specialized training and education", which includes medical assistants. So always be careful and follow office policies when working with patients.
If an employee acts bad, which includes harming a patient intentionally, or unintentionally, it can create liability for the employer if the bad act was committed on the job, performed as part of the job, and the kind of job that the employee was hired to do.
Assignments:
1. Read and study textbook pages 157-164
2. Complete the review questions on pages 170-172
3. Please view the video below:
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