Pt. Care Part 2 Flashcards
(15 cards)
What is the responsibility of a radiographer regarding electronic medical records?
To document patient information clearly, including condition and reactions to contrast agents
This includes the amount of contrast material injected and must adhere to institutional protocols.
What must be included in a patient’s chart by a radiographer?
Date and time of occurrence, clear statements regarding patient’s condition, and reactions to contrast agents
Radiographers must also sign chart entries.
How should errors in a patient’s chart be corrected?
Correct electronically or strike over once and rewrite the correct entry; never erase or obscure erroneous information.
What constitutes a radiographic image as a legal document?
It must include patient identification, anatomic markings, lead markers, and date of exposure
Markings added after exposure may not be legally admissible.
How long are radiographic images typically retained?
5 to 7 years after the last examination; mammograms and black lung images are kept for the patient’s lifespan.
For how long are files on minors typically retained?
5 to 7 years after the minor reaches age 18 or 21, depending on state law.
Is cropping or masking anatomy to simulate collimation acceptable?
No, it is never acceptable.
What rights does the patient’s bill of rights include?
Respectful care, up-to-date medical information, involvement in decision-making, privacy, confidentiality, and the right to view medical records
It also includes the right to decline participation in research studies.
What is implied consent?
Consent to care when the patient is unconscious, based on the assumption that the patient would approve if conscious.
What is valid consent also known as?
Informed consent.
What conditions must be met for valid consent?
Patient must be mentally competent, offered voluntarily, adequately informed, and of legal age
The radiographer must explain all procedure aspects and risks in lay terms.
What does HIPAA stand for?
Health Insurance Portability and Accountability Act.
What must hospitals do according to HIPAA?
Implement policies regarding the release of patient information
Patients must provide clear permission for release and be informed of how their information will be used.
What is a Do Not Resuscitate (DNR) order?
An order that may be placed when the patient’s quality of life has seriously declined or the condition is terminal.
Who must agree to a DNR order?
The physician and the patient, or a designated person holding power of attorney if the patient is incompetent.
