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what goes in report on vulnerable adult
same as child abuse
What are the grounds for appointing a guardian to a vulnerable adult?
if a person lacks sufficient understanding or capacity to communicate responsible
decisions, such a provision of health care, food, clothing or shelter because of mental
disability, disease, addiction; no less restrictive option will ensure safety of vulnerable
person.
required information on guardianship certificates for adults with
disabilities
(1) Examination signed off by 2 physicians or 1 psychologist and one physician; (2)
history of involvement of guardian with disabled person; (3) date of last exam; (4)
Assessment of disability as it relates to consent for guardianship.
What information is required on a certificate of involuntary admission for
an adult?
(1) based on personal examination of physician or psychologist; (2) includes a mental
dx; (3) includes an opinion about the necessity of inpatient care; (4) opinion that
admission is needed to protect the person being admitted or someone else
What needs to be included in a petition for an emergency evaluation?
petitioner's reasons to believe an individual: (1) has a mental disorder; (2) presents a
danger to the life or safety of themselves or others (p.140; 2015 regs)
What is a peace officer?
sheriff, deputy sheriff, police officers, secret service agent, agent of the Department of
Homeland Security. Can be a petitioner in an emergency evaluation request after
observing an individual's behavior.
health information exchange- definition
,infrastructure that provides organizational and technical capabilities for the exchange of
protected health information electronically among entities not under common
ownership.
person in interest- definition (Medical Records Act)
(1) an adult a provider maintains a record about; (2) person authorized to consent to
health care for an adult: (3) appointed representative of a deceased person; (4) minor, if
the minor has a right to consent for treatment; (5) parent, guardian, custodian, or
representative of the minor (parent- unless the authority to consent has been limited by
court order or valid separation agreement).
Protected health information - definition
all individually identifiable health information held or transmitted by a covered entity--
protected under HHS privacy rule.
Are disclosures included in a medical record
yes, to any person who is not an employee or agent of the health care provider.
disclosure of medical record it only allowed if
provided by title or law
who can authorize disclosure?
authorization by person of interest (adult patient, adult consenting for another,
representative of deceased person, minor if minor consented on own, parent/guardian
of minor patient at the discretion of physician, parent/guardian providing consent for
minor, attorney for a patient
what kind of disclosure is exempted from disclosure rules?
risk management, quality assurance, medical/dental/pharmacy review committee,
governed by substance abuse record rules, governed by intellectual disability rules,
directory information; child abuse/neglect; elder abuse/neglect
what are the parts of a valid authorization?
in writing, dated, signed; name of health care provider; identity of patient; period of
time authorization is valid, less than 1 year (except for criminal justice, valid until 30
days after final disposition, or nursing home, valid until revoked); apply only to the
medical record of the provider (unless in writing to include record from another
provider and that provider has not prohibited re-disclosure)
how do you revoke authorization
, in writing; efffective on day of receipt; disclosure made prior is not affected; does not
apply to criminal justice referrals
how do you document disclosures
medical record should include authorization, any action taken in response; any
revocation of authorization
how do you handle requests for copies of records
persons in interest have right to a copy, or to see and copy the medical record; can
refuse to give it if believe it will be injurious, but then if there is a written request, can
make a summary, keep a copy of the summary in the medical record; permit
examination and copying by another health professional authorized to treat the
individual for the same condition; inform the patient of right to pick a new provider
can patients ask to change their medical record?
yes, need procedures for this: - does not include deletion. After request, can make the
change or refuse to change it (in writing to the patient).
if you refuse to change medical record, what do you need to do?
1. tell patient, in writing, reason for refusal, and procedures established for review of
refusal 2. shall permit to insert a statement into medical record from patient about the
request, and a statement from you explaining refusal 3. shall write to anyone that was
given the record in the past 6 months to explain request for change or actual change in
the record
payments for costs of copying medical record
(includes medical bill, excludes x-rays) no more than 50 cents per page plus prep fee of
$15, actual cost of postage. can require payment in advance, except in emergencies.
cannot charge a government agency.
When is unauthorized disclosure of medical records allowable?
(1) to health care provider's authorized employees, students, consultants for seeking
payments; (2) to provider's legal counsel or insurer when addressing a claim against the
health care provider; (3) if the person given access signs an acknowledgement not to re-
disclose; reasons to be given access: -education or research; evaluation and
management of health care; -accreditation of the facility. (4) to another health care
provider treating the patient, with Special limitations for mental health
records; (5) billing to payors or insurers; (6) if a health care provider makes a
determination that immediate disclosure is necessary for emergency care; (7) to
immediate family members EXCEPT if patient has instructed providers NOT; does not
apply to mental health records; (8) to organ and tissue donors; (9) MD Dept of