Discussion 08.2: Missing Records
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9781284069754_SLID_CH18.pptxChapter 18
Legal Reporting Requirements
Learning Objectives
Describe various forms of child abuse, how to recognize it, and reporting requirements.
Describe various forms of elder abuse, how to recognize it, and reporting requirements.
Explain why it is important to report communicable diseases, adverse drug reactions, & infectious diseases.
Learning Objectives (cont’d)
Discuss the importance of reporting births and deaths.
Explain how & why physician incompetency is reported.
Understand the importance of incident reporting, sentinel events, & the purpose of root cause analyses.
Abuse
Abuse in the healthcare setting often occurs to those who are most vulnerable and dependent on others for care.
Abuse can take many forms, such as physical, psychological, medical, and financial.
Abuse is not always easy to identify because injuries can often be attributed to other causes.
Child Abuse
Intentional serious mental, emotional, sexual, &/or physical injury inflicted by family or other person responsible for care.
Child Abuse Prevention & Treatment Act (CAPTA)
Minimum standards states must incorporate in their statutory definitions of child abuse and neglect.
Child Abuse Who Should Report
Healthcare setting
Administrators, physicians, interns, registered nurses, chiropractors, social service workers, psychologists, dentists, osteopaths, optometrists, podiatrists, mental health professionals, & volunteers in residential facilities
Penalties for failure to report
States vary on penalties
Child Abuse How to Detect
Indicators of abuse and maltreatment that appear to be part of a pattern
Physical indicators
Bruises
Sprains
Fractures
Cigarette burns
Child Abuse How to Detect (cont’d)
Behavioral indicators
Diminished psychological or intellectual functioning
Failure to thrive
No control of aggression
Self-destructive impulses
Decreased ability to think and reason
Acting out and misbehavior, or habitual truancy
Child Abuse (cont’d)
Good faith reporting
Psychologist Immune to Liability
Failure to report child abuse
Psychologist’s Failure to Report Abuse
Nurse’s Failure to Document and Report
Physician Entitled to Immunity
Child Abuse Can Be Elusive
Senior Abuse
Mistreatment: Results in Harm or Loss
It can involve
Physical & Sexual Abuse
Domestic & Psychological Abuse
Financial abuse
Neglect
Failure to provide needed care
Senate Select Committee on Aging
Less Likely to be Reported than Child Abuse
Most Instances of Senior Abuse
Repeated Events
Not One-Time Occurrences
Senate Select Committee on Aging (cont’d)
Victims are often 75 years of age or older, & women more likely to be abused than men.
Seniors often ashamed to admit their loved ones abuse them.
may fear reprisals if they complain.
Family members are resentful of a frail & dependent senior parent.
Majority of abusers are relatives.
Signs of Senior Abuse
Unexplained or Unexpected Death
Development of “Pressure Sores”
Heavy Medication & Sedation
Inadequate nursing staff
Occurrence of Broken bones
Sudden Emotional Outbursts/Agitation/Withdrawal
Signs of Senior Abuse (cont’d)
Bruises, welts, discoloration, and burns
Absence of hair
Hemorrhaging below the scalp
Dehydration and malnourishment without illness-related cause
Hesitation to talk openly
Implausible stories
Signs of Senior Abuse (cont’d)
Unusual or inappropriate activity in bank accounts.
Signatures on checks and other written materials that do not resemble patient’s signature.
Power of attorney given, or recent changes or creation of a will, when person is incapable of making such decisions.
Signs of Senior Abuse (cont’d)
Missing personal belongings, such as silverware or jewelry.
An untreated medical condition.
Patient unable to speak for himself or herself, or see others, without presence of caregiver (suspected abuser).
National Center on Elder Abuse
The National Center on Elder Abuse (NCEA), directed by the U.S. Administration on Aging, is committed to helping national, state, and local partners in the field be fully prepared to ensure that older Americans will live with dignity, integrity, independence, and without abuse, neglect, and exploitation.
Preventing Abuse Policies and Procedures
Prohibition of Mistreatment
Description of Reporting Procedures Regarding Alleged Abuse
Maintenance of Evidence of Alleged Abuse
Investigation of Alleged Abuse
Prevention of further potential abuse while investigation is in progress
Abuse Documentation
Suspected abuse should be defined clearly and objectively.
Witnesses: Reporters of abuse must describe statements made by others as accurately as possible.
What actions were taken, by whom, when, where, etc.
Information should be included about how witnesses may be contacted.
Abuse Documentation (cont’d)
Photographs: It may be necessary to photograph wounds or injuries.
Hospital emergency room or the police department can be asked to photograph in emergency situations.
Communicable Diseases
Reported to Protect citizens from Infectious Diseases
Reporting Required by Statutes
AIDS
State HIV Required Reporting
Mandatory Testing
Births and Deaths
Reportable by Statute
Necessary to Maintain Accurate Census
Medical Examiner
Suspicious Deaths
Determines Cause of Death
Adverse Drug Reactions
Harmful Drug Reactions
Result of Administration of a Drug or Combination of Drugs
MedWatch
FDA Program for Reporting Harmful Reactions
Physician Competency
Health Care Quality Improvement Act
Authorizes National Practitioner Data Bank to collect & release information on professional competence & conduct of health care practitioners.
National Practitioner Data Bank
Created by Congress as national repository of information with primary purpose of facilitating a comprehensive review of healthcare practitioners’ professional credentials
Operates Under Authority of the Secretary of DHHS
Established to protect public by restricting ability of unethical or incompetent practitioners from moving state to state without disclosure or discovery of previously damaging or incompetent performance
National Data Bank Reporting
Reporting Requirements
Required Queries
Required Reporting
Data bank Queries
Query Fees
Penalties for Failing to Report
Confidentiality of Data Bank Information
Incident Reporting
States Reportable Incidents
Serious Injury or Death
Hospital Acquired Infections
Fires
Loss of Power
Employment Strikes
Incident Reporting, cont’d
The Deficit Reduction Act, amended in 2008, cites hospital-acquired infections Medicaid and Medicare will not reimburse hospitals for.
Catheter-associated urinary tract infections
Surgical site infections following bariatric surgery
Surgical site infections following certain elective surgery, & surgical site infections
Incident Reporting
Incident/Occurrence Reports Discoverable.
Incident Reports
Should Not be Placed in the Medical Record
Sentinel Events
Unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof.
“Or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Unanticipated Death
Major Permanent Loss of Function
Sentinel Events (cont’d)
Suicide
Unanticipated death of a full-term infant
Infant abduction
Rape
Hemolytic transfusion reaction
Surgery on the wrong patient or wrong body part
Root Cause Analysis
Process for identifying basic or causal factors that underlie the variation in performance including the occurrence or possible occurrence of a sentinel event.
Root Cause Analysis, cont’d
Thorough
Credible
Investigation involves general and special causes
Researching Literature
Search for Best Practices
Implementing & Monitoring Change
Review Questions
Describe various forms of child abuse, how to recognize it, & reporting requirements.
Describe various forms of elder abuse, how to recognize it, & reporting requirements.
Discuss importance of reporting births & deaths.
Review Questions (cont’d)
Explain why it is important to report communicable diseases, adverse drug reactions, & infectious diseases.
Explain how & why physician incompetency is reported.
Explain the importance of incident reporting, sentinel events, & the purpose of root cause analyses.
