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Flashcards in Practice Management Deck (20):
1

A 35-year-old woman is scheduled to undergo low-volume liposuction of the lower abdomen in an office setting. Intravenous sedation, in addition to local and tumescent anesthesia, is planned. Which of the following is essential to have in the operative suite according to the Guidelines for Office-Based Anesthesia?
A) Central venous catheter kit
B) Electrocautery unit
C) Intubation equipment
D) Tracheostomy set
E) Warming blanket

C) Intubation equipment

To ensure patient safety during office-based procedures, a system of quality care needs to be established in each facility, emphasizing maintenance of the appropriate facilities, equipment, personnel, protocols, and procedures.

When administering anesthesia of any kind in an office setting, the surgeon should follow the American Society of Anesthesiologists’ “Guidelines for Office-Based Anesthesia,” and “Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists.”

The facility should be outfitted with the appropriate medical equipment, materials, and drugs necessary to provide anesthesia, recovery ministration, cardiopulmonary resuscitation, and provisions for potential emergencies. Anesthesia equipment should include suctioning apparatus, appropriately sized airway equipment, including laryngoscope blades, means of positive-pressure ventilation, intravenous equipment, pharmacologic antagonists, basic resuscitative medications, and, in the event of deep sedation, defibrillator equipment.

Additional equipment, such as a central venous catheter kit, electrocautery unit, warming blanket, and tracheostomy set may be desirable based on the type of patients and/or cases being performed, but are not considered essential in the case of the patient described.

2

Based on the code of ethics of the American Society of Plastic Surgeons, which of the following actions, if committed by a member, can be cause for disciplinary action?
A) The board-eligible surgeon chooses to advertise in an airline magazine
B) The member chooses to place patient testimonials on his or her Web site
C) The member participates in a charity raffle, fund-raising event, contest, or other promotion in which the prize is nonsurgical facial rejuvenation
D) The member uses his or her own before-and-after photos on the Web site
E) The out-of-network member charges wholly disproportionate fees for emergency care

E) The out-of-network member charges wholly disproportionate fees for emergency care

Disciplinary actions can be taken for charging exorbitant fees, particularly of a non-contractual nature (e.g., emergency care). Fees are exorbitant when they are wholly disproportionate to the services rendered. The reasonableness of fees depends upon the novelty and difficulty of the procedures involved, the skill required to provide proper care, the time and labor required, the fee charged for similar services by similarly situated peers, and whether or not the patient had agreed in advance to the fee. Except in instances of emergencies or urgent and life-threatening disease or injury, nothing in this principle shall be construed to prohibit a member from requiring prepayment of professional fees for all elective surgical operations.

Sanctions can be taken if the member participates in a charity raffle, fund-raising event, contest, or other promotion in which the prize is any procedure defined as a medical service that requires an incision. Examples of services that require an incision include, but are not limited to, rhytidectomy, augmentation mammaplasty, blepharoplasty, and liposuction. Examples of medical services that would not be considered procedures include, but are not limited to, injections (botulinum toxin, hyaluronic acid), microdermabrasion, and other skin surface treatments. Nonsurgical means do not fall under this category.

Sanctions can be taken if the Web site contains a testimonial pertaining to the quality and efficacy of medical care if the experience of the endorser does not represent the typical experience of other patients or if, because of the infrequency and/or complexity of such care, results in other cases cannot be predicted with any degree of accuracy. Also, sanctions may be taken if it contains a testimonial or endorsement pertaining to the quality of the member’s medical care or the member’s qualifications if the endorser has been compensated by the member or a third party retained by the member for making such testimonial or endorsement. Honest, well-represented, unbiased, uncoerced testimonials are allowed.

Disciplinary actions can be taken if the Web site contains photographs, images, or facsimiles of persons who falsely or deceptively portray a physical or medical condition, injury, or disease, including obesity, or recovery of relief therefrom; or if it contains photographs, images, or facsimiles of persons who have received the services advertised, but who have experienced results that are not typical of the results obtained by the average patient, without clearly and noticeably disclosing that fact; also, if it contains photographs, images, or facsimiles of persons before and after receiving services, which use different light, poses, or photographic techniques to misrepresent the results achieved by the individual.

3

According to the Health Insurance Portability and Accountability Act's Security Rule, which of the following is the basic requirement for storing patient photographs on a personal computer?
A) De-identification of patient names in files
B) Encryption using an approved process
C) Institutional review board approval
D) Password protection of the personal computer
E) Storage of patient photographs is not permitted on personal devices

B) Encryption using an approved process

According to the U.S. Department of Health and Human Services, “the Health Insurance Portability and Accountability Act (HIPAA) Security Rule establishes national standards to protect individuals’ electronic personal health information (ePHI) that is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information.” To this end, HIPAA requires that ePHI be protected using encryption processes that have been tested by the National Institute of Standards and Technology and judged to meet this standard.

Password protection can prevent access to electronic devices but does not allow for data on a device to be deleted in the event of a breach. De-identification of file names does not change the electronic information that is stored within a file and, therefore, is inadequate in protecting ePHI. Institutional review boards are primarily responsible for reviewing and monitoring research that involves human subjects and are generally separate from HIPAA-related regulations.

4

Which of the following is a standard for accreditation of an ambulatory surgery facility as it relates to plastic surgeons?
A) All team members of the ambulatory facility caring for pediatric patients must be certified in Pediatric Advanced Life Support
B) Ambulatory facilities are inspected every 5 years
C) Patients undergoing ambulatory surgery during general anesthesia require a responsible adult to monitor them for 1 to 2 hours after discharge from the ambulatory surgery center
D) Plastic surgeons working in the ambulatory surgery facility must be board certified by the American Board of Plastic Surgery
E) Surgeons operating in an ambulatory surgery center are required to demonstrate that they hold unrestricted hospital privileges at an acute-care hospital within 30 minutes’ driving time of the facility

E) Surgeons operating in an ambulatory surgery center are required to demonstrate that they hold unrestricted hospital privileges at an acute-care hospital within 30 minutes’ driving time of the facility

The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) requires surgeons to be Board Certified or Board Eligible with a Board recognized by the American Board of Medical Specialties. A patient who underwent general anesthesia needs a responsible adult to supervise him/her for 12 to 24 hours. Surgeons are required to demonstrate that they hold unrestricted hospital privileges at an acute-care hospital within 30 minutes’ driving time of the ambulatory facility. If pediatric patients are cared for, at least one member of the team needs to be certified in Pediatric Advance Life Support (PALS). Ambulatory care facilities are inspected every 3 years by the AAAASF.

5

A 5-year-old girl, who is a Jehovah’s Witness, is scheduled to undergo extensive cranioplasty. Bloodless surgery has been scheduled at an institution offering a blood conservation program. During the procedure, the patient becomes hemodynamically unstable from excessive, ongoing intraoperative bleeding and is found to have a hemoglobin level of 6.0 g/dL. The patient’s parents refuse to consent to a blood transfusion. Which of the following is the most appropriate next step in management?
A) Administration of blood products
B) Administration of erythropoietin
C) Initiation of vasopressors
D) Resuscitation with albumin
E) Resuscitation with hypertonic saline

A) Administration of blood products

The issue of religious beliefs and medical management is a difficult ethical scenario that can arise in the care of pediatric patients. It is generally accepted in many countries with the support of international law that a minor should not be put at risk because of the religious beliefs of his/her parents. In this case, a blood transfusion is clearly needed but is not a medical treatment accepted by Jehovah’s Witnesses. In the United States, the American Academy of Pediatrics recommends that in cases of “an imminent threat to a child’s life,” physicians in some cases may “intervene over parental objections.” In general, a contingency of bloodless surgery programs for pediatric patients is the reservation of the legal right to give blood if an emergent need arises, despite the lack of parental consent. It is generally accepted that blood products may be given to minors if it is in the best interest of the patient despite parental religious beliefs or other objection. This course of action has been supported a number of times in the court of law.

6

A 46-year-old woman receives several thousand dollars’ worth of injectable filler and neurotoxin treatments following an initial consultation with the plastic surgeon. Before receiving the injections, she indicated that she understood the planned treatments and was made aware of the costs. She provided informed consent and paid for the services with a credit card. The plastic surgeon calls the patient for follow-up several weeks after the treatment, and the patient reports being happy with the results. Several months later, the plastic surgeon receives a notice from the credit card company that the patient is now disputing the charges, and the credit card company promptly removes the fees from the plastic surgeon’s account. Which of the following is the most appropriate action by the plastic surgeon in response to this situation?
A) Call the patient and advise her that her charges will be turned over to the police for fraud
B) Call the patient who referred her and ask if she could encourage this patient to reverse the charges
C) Contact a lawyer to consider legal action against this patient
D) Ensure that all future patients sign a policy in advance of any treatment that waives their privacy protection under HIPAA in matters of dispute of payment
E) Send documentation to the credit card company of the treatments the patient received and proof that she had signed informed consent

D) Ensure that all future patients sign a policy in advance of any treatment that waives their privacy protection under HIPAA in matters of dispute of payment

Although it may seem aggressive to have patients sign a financial policy before receiving treatment stating that if there are any matters in dispute after the fact, they waive their right to privacy under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) guidelines, this is the only way in which a case like this may be successfully handled. Without such protection, no information (including the fact that the person was even a patient) may be shared with a credit card company, another patient, the police, or a collection agency because it would be a violation of HIPAA, even if appropriate informed consent were obtained. Calling a patient with any kind of threat about a financial matter should never be done because this would violate ethical standards. Without a patient specifically waiving his/her right to privacy under HIPAA in a signed document, no information about that patient may be shared with the credit card company, and the physician is unable to confirm that the patient is indeed under his care. HIPAA affords complete protection of a patient’s privacy, and, in situations such as these, to the great disadvantage of physicians who accept credit cards for payment. Any dispute cannot be properly addressed by the physician without a patient signing away these rights specifically.

7

A 17-year-old girl comes to the office for evaluation for an abdominoplasty 1 year after the delivery of her first child. Following evaluation, the patient is deemed a good surgical candidate. The patient is married, but she came to the consultation alone. Which of the following is the most appropriate next step?
A) Obtain consent from her husband
B) Obtain consent from one parent
C) Obtain consent from the patient
D) Re-evaluate the patient at 18 years of age
E) Re-evaluate the patient at 21 years of age

C) Obtain consent from the patient

The most appropriate next step in management is to perform the abdominoplasty without parental consent. Because the patient is married and has a child, she is an emancipated minor and is legally able to consent to medical procedures. The criteria for an emancipated minor generally include: marriage, military service, financial independence, living arrangements apart from the parents, and parenthood. Almost all states allow patients age 18 years or older to give their own consent for a medical procedure; non-emancipated patients younger than age 18 years require the consent of one parent.

8

A 22-year-old woman comes to the office for consultation because she is dissatisfied with the appearance of her nose. History includes two cosmetic procedures of the nose. During the consultation, she also expresses dissatisfaction with the appearance of her eyelids, chin, lower abdomen and flanks, and breast size. In this patient with body dysmorphic disorder, which of the following additional findings is most likely?
A) Anorexia
B) Anxiety disorder
C) Depression
D) Hypochondriasis
E) Substance abuse

C) Depression

The demographic features of body dysmorphic disorder include an onset during late adolescence, and it appears to affect men and women with equal frequency. The clinical features of body dysmorphic disorder most frequently include preoccupation with the appearance of the skin, hair, and nose, although any body part can be a source of concern.

Although several psychiatric comorbidities have been associated with body dysmorphic disorder, depression is the most common. In one study, over 75% of patients with body dysmorphic disorder had a lifetime history of major depression, and over half met criteria for current major depression.

The remaining psychiatric disorders listed also occur with body dysmorphic disorder, but in lower frequencies. Lifetime rates of substance abuse disorders in patients with body dysmorphic disorder have been shown to be close to 30%. Similarly, the lifetime history of an anxiety disorder in patients with body dysmorphic disorder was reported to be more than 6%. The same study reported the lifetime comorbidity rate of anorexia to range from 7 to 14%.

Body dysmorphic disorder and hypochondriasis both involve obsessional thinking and checking behaviors, but the focus of concern in body dysmorphic disorder is on appearance, whereas in hypochondriasis the concerns relate to health status. One study found that only 2% of their body dysmorphic disorder sample had comorbid hypochondriasis.

9

assistant obtains the patient’s history, and the plastic surgeon performs a brief history and comprehensive physical examination. The patient is considered a good candidate for surgery, and without further discussion the medical assistant is left to obtain a generic hospital consent form. The patient signs the form without a witness present. The surgeon is at increased medico-legal risk because of which of the following?
A) Lack of a specific plastic surgery consent form
B) Lack of verbal discussion of the risks of reduction mammaplasty
C) Lack of a witness signature on the consent form
D) Use of a medical assistant in the consultation
E) The physician is not at risk because the patient signed a consent form

B) Lack of verbal discussion of the risks of reduction mammaplasty

This surgeon is at increased medico-legal risk due to the fact that there was a lack of verbal discussion of the risks of reduction mammaplasty. Three components must exist for a patient to give informed consent: disclosure, capacity, and voluntariness. In this case, the lack of verbal communication regarding the risks of reduction mammaplasty represents a lack of disclosure. Use of a medical assistant is accepted practice and does not increase the physician’s risk in and of itself. One cannot rely on written documents alone, which may or may not be read or understood by the patient. Although a witness signature is required by many hospitals, the presence of a witness is not a central component of the informed consent process. A specific plastic surgery consent form can be helpful, but only if the risks pertaining to the plastic surgery procedure are discussed in person with the patient. Use of a generic hospital consent form is common and acceptable, provided a verbal discussion of the particular risks associated with the proposed procedure occurs and is documented elsewhere in the medical record.

10

Which of the following individuals is at highest risk of dissatisfaction with the surgical outcome?
A) A 25-year-old man with a large amount of excess skin following a 100-lb (45-kg) weight loss who comes to the office for body contouring
B) A 35-year-old woman who comes to the office for facial rejuvenation surgery in order to advance her career as a news anchor
C) A 42-year-old woman who comes to the office with a large nasal dorsal hump and bulbous tip who is requesting an improved appearance
D) A 45-year-old mother of three with marked deflation and ptosis of the breasts who is looking for an improved appearance
E) A mother of a 3-year-old girl who brings the child in for surgery for a large congenital nevus

B) A 35-year-old woman who comes to the office for facial rejuvenation surgery in order to advance her career as a news anchor

One of the psychological contraindications to plastic surgery is when a patient gauges the success of surgery on realization of a specific goal (i.e., a job promotion). Others include the patient who is unable to contemplate an imperfect result, uncertain as to which aspect to change, under emotional stress during consultation, motivated to have surgery at the request of others, and a doctor-shopper dissatisfied with the results of multiple previous procedures.

There are multiple contraindications to surgery: some anatomical and some psychological. One of the most important decisions by a surgeon is whether to perform the requested surgery. The plastic surgeon has to identify a correctable deformity or concern first. This then has to be balanced against the importance that the patient places on this deformity. According to Gorney, the patient with minor deformity but extreme concern is most likely dissatisfied with whatever the outcome. Additionally, the surgical outcome has little to do with the emotional stress.

The dissatisfied patient, once discovered postoperatively, must be handled carefully. This patient must be seen frequently and offered compassion and concern. Allow the patient to see you as the ally that you are. Offer a waiting period before performing any other operations. Consider an offer to revise an operation only if you concur with the patient’s complaints and you think you can improve the appearance. Also, sit with the patient and have a frank discussion of his/her complaints.

All the other options in the question present patients with real identifiable, correctable problems with reasonable expectations.

11

A 67-year-old man undergoes excision of a squamous cell carcinoma from the tip of his nose. The patient’s daughter, who is a physician, asks for the pathology results. Which of the following is the most appropriate response?
A) Ask the patient’s daughter to provide proof of her medical licensure
B) Have the patient’s daughter complete a medical records release form
C) Obtain the patient’s consent to release the results to his daughter
D) Refer the patient’s daughter to the pathology lab
E) Release the pathology results to the patient’s daughter

C) Obtain the patient’s consent to release the results to his daughter

According to the Health Information Portability and Accountability Act (HIPAA) of 1996, it is a violation to provide personal health information about a patient without the patient’s expressed consent. Consent is ideally documented in the medical record and signed by the patient. According to HIPAA, there are specific Permitted Uses and Disclosures. A physician is “permitted, but not required, to use and disclose protected health information, without an individual’s authorization, for the following purposes or situations: 1) To the Individual (unless required for access or accounting of disclosures); 2) Treatment, Payment, and Health Care Operations; 3) Opportunity to Agree or Object; 4) Incident to an otherwise permitted use and disclosure; 5) Public Interest and Benefit Activities; and 6) Limited Data Set for the purposes of research, public health or health care operations. Covered entities may rely on professional ethics and best judgments in deciding which of these permissive uses and disclosures to make.” Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.

12

A plastic surgeon flies home after taking her oral American Board of Plastic Surgeons (ABPS) examination. She is excited to finally start advertising to the public in order to grow her practice. She enlists an endorsement from one of her satisfied patients who underwent augmentation mammaplasty. The patient provides a quote and allows her photograph to be used. The plastic surgeon also wants to highlight her additional fellowship training in breast surgery. She is an American Society of Plastic Surgeons (ASPS) candidate member. Inclusion of which of the following items in her advertisement would be a breach of the ASPS Code of Ethics?
A) ASPS logo
B) Assertion of advanced skills in breast surgery as a result of her breast fellowship
C) A list of her plastic surgery training programs
D) Testimonial of the patient stating that this is the best plastic surgeon she knows

A) ASPS logo

The plastic surgeon described is board eligible, not board certified, and a Candidate Member of the ASPS. She cannot use the logo until she is a member of the ASPS, and she must first be board-certified. She cannot assume she has passed her oral board examination until the board contacts her to let her know this. Using the ASPS logo in advertising is a breach of the ASPS Code of Ethics without board certification and full membership in the ASPS.

Claims highlighting the fact that she is a female plastic surgeon to attract female patients do not represent a breach of the Code of Ethics, nor is sharing her educational history. She has enlisted her patient’s endorsement, and use of a direct quotation as a testimonial from the patient is fine if it is clearly a quote from the patient. The plastic surgeon needs to be careful, because other plastic surgeons in her area may think she is breaching the Code of Ethics with claims of superiority, as stated in Section 2IG: The member, either personally or through a partner or associate or any physician or other affiliated health care provider, uses or participates in the use of any form of public or private communication (including computer imaging and electronic communications) containing a false, fraudulent, deceptive, or misleading statement or claim.

13

A 42-year-old man who is a close friend of the on-call plastic surgeon is brought to the emergency department because of a metacarpal fracture. He is being treated by the on-call orthopaedic surgeon. The patient's wife sees the plastic surgeon and asks to view her husband's post-reduction x-ray studies. Which of the following is the most appropriate response?
A) Confirm only that the x-ray study was completed
B) Obtain verbal consent from the patient
C) Review the x-ray studies with the spouse
D) Share the report without showing the x-ray studies
E) View the x-ray studies with the radiologist

B) Obtain verbal consent from the patient

The most appropriate response is to obtain consent from the patient to access his medical record. Confirming that the x-ray studies have been performed, sharing the report, viewing the x-ray studies in person with the radiologist, and reviewing the x-ray studies with the spouse would require accessing the patient’s medical record, for which the plastic surgeon has not obtained consent. Doing so would be a violation of the Health Insurance Portability and Accountability Act (HIPAA).

14

During a procedure with general anesthesia, a 26-year-old male intern is told that the patient in the operating room next door has a very interesting tattoo on her lower abdomen. He takes a picture of the tattoo with his cell phone. This action is a violation of which of the following health care regulations?
A) Consolidated Omnibus Budget Reconciliation Act
B) Emergency Medical Treatment and Active Labor Act
C) Health Insurance Portability and Accountability Act
D) National Health Security Strategy
E) Patient Protection and Affordable Care Act

C) Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted by the US Congress in 1996. Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. The AS provisions also address the security and privacy of health data. They allow the protection of individuals’ health information, while also allowing communication between parties involved with patient care. The privacy rule outlines six permitted disclosures of individual health information including the following: per request of the patient, for treatment or payment, to individuals identified by the patient, incidental disclosure, limited data set with removal of individual identifiers, and public interest such as organ donation. Identifiable health information is treated as patient property.

Portable media devices and smartphones also have the ability to store data. Digital pictures and videos taken by cell phones are commonplace, and technology exists that can directly download to the Internet. Breach in HIPAA compliance from this new technology is viewed with increasing scrutiny, especially when patient features are identifiable. In addition, personal digital assistants (PDAs), cell phones, or other devices with appropriate patient lists, properly consented pictures, or other data should be password-protected and data properly disposed, destroyed, or used. Computer hard drives must be demagnetized, overwritten, and/or physically destroyed when disposed.

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a US Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospitals to provide care to anyone needing emergency health care treatment regardless of citizenship, legal status, or ability to pay.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (or COBRA) is a law passed by the US Congress that mandates an insurance program giving some employees the ability to continue health insurance coverage after leaving employment.

The National Health Security Strategy (NHSS) is a strategic plan developed by the US Department of Health and Human Services that is intended to minimize the health consequences associated with significant health incidents. The NHSS is a provision of the Pandemic and All Hazards Preparedness Act (PAHPA). The purpose of the NHSS is to ensure that the nation is prepared for health threats or incidents.

The Patient Protection and Affordable Care Act (PPACA) is a US federal statute signed into law in 2010. PPACA reforms certain aspects of the private health insurance industry and public health insurance programs, increases insurance coverage of pre-existing conditions, and expands access to insurance to over 30 million Americans.

15

Which of the following is a critical feature required to obtain the optimal reproducible digital photographs for valid pre- and postoperative comparison?
A) Lens with a focal length of 90 to 105 mm
B) Matching anatomical landmarks
C) Single flash
D) Three-dimensional capability
E) White background

B) Matching anatomical landmarks

There have been numerous publications on subtopics in clinical photography. Clinical photographs should be taken with the same camera lens, lens setting, lighting, film, and patient position to ensure reproducibility and to enable valid pre- and postoperative comparisons. Specific anatomical landmarks are used as guides for positioning each pose. These landmarks should be used each time to ensure the exact duplication of poses. A grid pattern can also be used. Two lenses are recommended. A single lens with a focal length of 50 to 60 mm with macro capability is required as a minimum, although the longer focal length lens of 90 to 105 mm can aid in facial photography close-ups. At least two light sources are required to avoid flatness and shadowing. An even, uncluttered background is best, with a color such as sky blue that is most visually pleasing with skin tones. This can be painted on a wall, paper, or retractable fabric. Three-dimensional capability is useful for volumetric evaluation and changes, but is not yet standard of care in plastic surgery photography.

16

A 45-year-old man approaches his neighbor, a plastic surgeon, at a cocktail party. He was seen in the emergency department 1 day ago with a broken toe and was given a prescription for ibuprofen. He says his toe is still aching and asks for a prescription for acetaminophen with codeine, which he has taken before. The plastic surgeon asks the man about his medical history, and a physical examination shows "buddy" taped toes and moderate ecchymosis and swelling. The plastic surgeon writes the prescription for acetaminophen with codeine. Which of the following is the most necessary next step for the plastic surgeon?
A) Contact his treating physician
B) Have the man sign a Health Insurance Portability and Accountability Act (HIPAA) consent form
C) Order a repeat x-ray study
D) Send the man to the emergency department
E) Write a medical note of the encounter

E) Write a medical note of the encounter

The key to the scenario described is that the plastic surgeon is out of the office and the man is not his patient. However, as soon as a prescription is written, he is now a patient, and the plastic surgeon is obligated to document this encounter. A prescription is a legal document and as such is subject to local, state, and federal laws. Each state has its own individual laws, many of which are very restrictive, demanding taking a history and conducting a physical examination before prescribing as well as maintaining written records of all treatments and prescriptions. Federal law limits its prescription writing laws to controlled substances. These laws require that the prescriber have a bona fide patient-physician relationship with any person for whom he or she prescribes controlled substances. This relationship includes maintenance of a written medical record. Violating these standards can jeopardize a license.

Contacting his treating physician is unnecessary.

Sending the man to the emergency department or ordering an x-ray study is unnecessary.

HIPAA stands for the Health Insurance Portability and Accountability Act. This rule set national standards for the protection of individually identifiable health information.

Having the form signed would not be the most appropriate next step.

17

Which of the following is included in the principles of informed consent regarding augmentation mammaplasty?
A ) Alternatives to the procedure
B ) Appropriate safeguards to protect the privacy of personal health information
C ) Costs of the procedure
D ) Photographic release
E ) Requirement for arbitration

A ) Alternatives to the procedure

Alternatives to the procedure are part of an informed consent that also includes benefits and consequences. Although it may be argued that there are not many reasonable alternatives, there is always the option to decline cosmetic surgery. Likewise, both saline and silicone gel prostheses are options regardless of the preferences of the surgeon. Other items of informed consent include the nature of the surgery or treatment; indications for the procedure; expected benefits, consequences, and side effects of the procedure; potential risks and adverse outcomes, along with their probability and severity; alternatives to the procedure being considered; the benefits, risks, and consequences of the stated alternatives; and outcome anticipated.

Appropriate safeguards to protect the privacy of personal health information are required by the Health Insurance Portability and Accountability Act (HIPAA), not by informed consent. Discussing costs of the procedure, as well as the costs of revisions, is a part of good practice and may avoid litigation and dissatisfied patients; however, it is not required as part of informed consent. A photographic release is an important part of patient care in plastic surgery and serves as useful documentation, but it is not part of informed consent. Requirement for arbitration might be helpful to avoid litigation but is not part of informed consent and is not beneficial in states that feel physicians have a better understanding of medical matters.

The six elements of valid informed consent include diagnosis or suspected diagnosis; the nature and purpose of the proposed treatment or procedure and its anticipated benefit; the risks, complications, or side effects associated with the proposed treatment or procedure; the probability of success based on the patient’s condition; reasonable, available alternatives; and the possible consequences to the patient if the recommendations are not followed.

18

A 55-year-old woman is referred to the office by her oncologist because of a chronic ventral hernia. Hernia repair is planned. Before the procedure, the patient says she would also like an abdominoplasty during the same operation. She wonders if her insurance can be billed for the procedure or a similar one, such as a panniculectomy. Which of the following is the most appropriate management of this patient's request?
A ) Collect payment from the patient for the costs related to the abdominoplasty
B ) Perform the abdominoplasty and hernia repair and bill the patient?s insurance for both procedures
C ) Refuse to take the case because it is fraudulent to perform any cosmetic procedures in conjunction with reconstruction
D ) Schedule the procedure as a panniculectomy, perform the abdominoplasty, and bill the insurance for the panniculectomy

In the scenario described, it is most appropriate to explain to the patient that she will need to be billed separately for the cosmetic portion of the procedure and associated anesthesia. Insurance companies will not cover elective cosmetic procedures.

When performing both a reconstructive and cosmetic procedure, one must inform the operating staff at what point the elective cosmetic portion has begun. This will allow for the patient to be separately billed for anesthesia and operating room fees. Codes submitted for reimbursement of insurance coverage should represent only the reconstructive portion of the procedure.

It is not fraudulent to perform elective cosmetic and reconstruction procedures at the same time.

It is never acceptable to perform one procedure and bill for a second in the hope of being reimbursed.

19

A plastic surgery resident is participating in a study that involves review of outcomes of patients with breast cancer who underwent immediate breast reconstruction with tissue expanders during the past 10 years and have subsequently received radiation therapy. In collecting these data within the guidelines of the Health Insurance Portability and Accountability Act (HIPAA), which of the following patient characteristics can be collected without patient consent?
A ) Age
B ) E-mail address
C ) Medical record number
D ) Name
E ) Telephone number

A ) Age

The Health Insurance Portability and Accountability Act (HIPAA) was amended to include the Standards for Privacy of Individually Identifiable Health Information, i.e., the Privacy Rule, to protect the privacy of medical records. Implementation of the new regulations was mandatory as of April 14, 2003.

The HIPAA Privacy Rule states that patients must be notified of their rights with respect to their medical information, including the right to restrict the use and disclosure of such information, the right to inspect and copy their records, the right to amend their records, and the right to an audit of any disclosure of their records. Covered entities including health plans, health care clearinghouses, and health care providers are required to obtain specific written authorization from a patient to use or disclose health care information that is linked to that patient. This includes medical records used for the purpose of medical research.

Patient authorization can be waived and medical records accessed without institutional review board (IRB) review or individual patient consent in two circumstances: preparing a research protocol, as long as access to medical records is needed for its preparation, and no protected medical information is removed from the site; and performing research that concerns only people who have died. In all other cases, waivers can only be obtained from an IRB or privacy board if specific criteria are met. Once a waiver is granted, the medical information must be ?de-identified? in one of two ways. The first is for a knowledgeable statistician to determine that the risk of identifying an individual patient from the information disclosed or used is 'very small' and to document the methods and results used to arrive at this conclusion. The second is to strip the records of identifiers including name; address; telephone and fax numbers; e-mail address; Social Security, medical record, health plan, and account numbers; certificate, license, vehicle, and medical-device serial numbers; biometric identifiers; full-face photographs; and any other unique identifying number, characteristic, or code to provide legal protection against the charge of a violation of privacy.

The collection of age (but not date of birth) and gender of patients from medical records for a retrospective research study are not identifiers that violate this policy.

20

Which of the following statements is most appropriate to ask when interviewing a potential hire?
A ) If the applicant has any physical disabilities
B ) What the applicant's age is
C ) What the total amount of hours the applicant is available to work per week
D ) Whether the applicant has ever been arrested
E ) Whether or not the applicant has children

C ) What the total amount of hours the applicant is available to work per week

Employment practices include measures of personnel management principles as well as knowledge of state and federal laws governing the hiring of employees. Plastic surgeons and office managers must comply in accordance with guidelines in government publications and practice management handbooks. The hours worked per week and the likelihood for overtime may be discussed but no promises of total monthly or annual hours should be made to any candidate lest a contract be implied. Among the questions that interviewers should always avoid are those relating to the candidate’s age, religion, country of origin, race, child care responsibilities, health-related disabilities, and arrest history. While inquiring about prior arrests should be avoided, knowledge of the applicant’s prior convictions for such acts as embezzlement from a former employer or violent crime activities is pertinent. A background check may elucidate this more clearly and help to avoid a potential lawsuit.