Fundamentals of Medical Practice Investigation by Lane, Jeffrey D. -- Read -- Imperial Library of Trantor

Index

Cover Half Title Title Page Copyright Page Dedication Table of Contents Preface Disclaimer Acknowledgments Author Chapter 1 Medicine and the investigation thereof

Definition The standard of care Two broad approaches to medicine

Allopathic medicine Osteopathic medicine

Investigation References

Chapter 2 Professional ethics

Hippocratic Oath Professional ethics

Profession Ethics

The Four Principles Approach

Autonomy Beneficence and nonmaleficence Justice

Influencers of unethical behavior

The ethical investigator Ethical decision making

References

Chapter 3 The regulation of the practice of medicine

How physicians gain licensure How state medical boards regulate physicians after licensing Difference between a medical board disciplinary action and malpractice Sharing of information How state medical boards serve the public State medical board physician profiles Physician discipline statistics The Medical Practice Act References

Chapter 4 The investigative process

Definition and purpose of an investigation Attributes of an effective investigator Survey of state medical practice acts Initial complaint review References

Chapter 5 Witness interviews and respondent interviews

Witness interview Time, location, and setting of the interview Preparation for the interview

Preparation Introduction Body Conclusion

Developing pertinent questions Asking the question Listening and observing Documenting the interview Interview review Respondent/subject interview

The Miranda warning Logical approach Emotional approach

Verbal and nonverbal responses

Truthful verbal responses Untruthful verbal responses Nonverbal responses

References

Chapter 6 The medical record

The medical chart and its purpose Obtaining a medical record Reviewing the medical record

Comparative table Time line Parts of the medical record

Ambulance call report or ambulance trip sheet Emergency department record Face sheet Admission note/history and physical Radiology note Consult note Informed consent Operative note or procedure note Anesthesia note Physician order sheet Progress note Nursing notes Medication administration record Laboratory and pathology reports Discharge summary Incident reports

Autopsy report Altering and falsifying the medical record Detecting chart tampering Strategies to detect altered medical records Properly correcting the medical record

References

Chapter 7 Evidence and evidence handling

Purposes of evidence Types of evidence Rules of evidence

Exclusionary rule Hearsay rule

Authentication of documentary evidence Obtaining evidence Voluntary relinquishment Subpoena Search warrant Chain of custody References

Chapter 8 Standard of care investigations

Definition Medical malpractice Physician/patient relationship Common SOC issues

Failure to obtain consultation and referral Physician/patient communication failure Failure to diagnose/misdiagnosis

Treatment errors

Prescribing of drugs Investigation

Interview of complainant Interview of witnesses

Obtaining records Reviewing the records

Interview of the respondent Peer review References

Chapter 9 Controlled substance prescribing investigations

Definitions Opioids/narcotics

Effects on the brain and body Potential consequences of opioid use and abuse

Stimulants

Effects on the brain and body Potential consequences of stimulant use and abuse

Central nervous system (CNS) depressants

Effects on the brain and body Potential consequences of CNS depressant use and abuse Tolerance versus dependence versus addiction

Tolerance Dependence Physical dependence Psychological dependence Addiction Regulation

21 CFR § 1306.04 Purpose of issue of prescription 21 CFR § 1306.05 Manner of issuance of prescriptions

Scope of the problem Prescription drug monitoring programs

Investigation Covert approach Overt approach

Interview of complainant and witnesses Collecting pharmacy data Organizing the pharmacy data Reviewing the pharmacy data Obtaining patient records Reviewing the patient records Interviewing the physician Internet prescribing References

Chapter 10 Professional sexual misconduct investigations

Definition Boundaries Boundary blurring Dual relationships Sexual impropriety Boundary transgressions Sexual violations Investigation Interview of complainant Interview of victim/patient Assessing the victim/patient’s credibility Interview of witnesses Documentary evidence Interview of the respondent/physician Assessing the physician’s credibility Potential outcomes References

Chapter 11 Mental and physical impairment investigations

Definitions Illness versus impairment Substance abuse/addiction

Definitions

Substance Substance use disorder (according to DSM-IV) Addictive illness

Psychiatric disorders Disruptive behavior

Inappropriate behaviors Inappropriate words or actions Inappropriate responses to patient needs or staff requests

Physical and medical disability and the aging physician Physician health programs Investigation

Self report Report from family, co-worker, pharmacist, et al. Physician interview Report of adverse action by hospital or practice

References

Chapter 12 Investigating healthcare fraud

Scope of the problem Definitions

General definition of fraud Definition of healthcare fraud

Federal statutes relating to healthcare fraud Health Insurance Portability and Accountability Act of 1996 Types of fraud schemes

Billing for services not rendered Up-coding of services Up-coding of medical equipment and devices Substitute providers/misrepresenting the provider of service Unnecessary or excessive tests or services Unnecessary surgeries and procedures Unbundling Misrepresenting noncovered treatments as medically necessary Kickbacks

Investigation

Complainant interview Witness interviews Benefit program data Patient interviews Obtain patient charts Review patient charts Interview of suspect provider

References

Chapter 13 Other investigative concerns

Criminal convictions Hospital adverse actions Disciplinary actions taken by another jurisdiction Settlements and judgments of malpractice suits Fraud when applying for licensure References

Chapter 14 Investigating the unlicensed practice of medicine and complementary and alternative medicine

Elements of the offense Complementary and alternative medicine Prevalence of the use of CAM Ethical issues

Autonomy

Beneficence and maleficence

Justice

Legal status of CAM Ethnic and cultural practices

Investigation

Overt investigation Interview of complainant/source of information Interview of other witnesses Interview of patients Obtaining evidence Covert investigation Interview of suspect practitioner

Telemedicine Licensure

Establishment of a physician-patient relationship

Evaluation and treatment of the patient Informed consent

Continuity of care Referrals for emergency services Medical records Privacy and security of patient records and exchange of information Disclosures and functionality on online services making available telemedicine technologies

Prescribing

What services can be provided by telemedicine? Benefits of telemedicine References

Chapter 15 The report of investigation

Purpose of the ROI Characteristics of an effective ROI The 4 Cs of effective report writing

Correct Concise Clear

Guidelines for clarity

Complete

Who What When Where How Why

Report writing process

Introduction Body Conclusion

References

Chapter 16 The trial and hearing process and the investigator as a witness

The concept of due process of law

Burden of proof Reasonable doubt Preponderance of the evidence Trial and hearing process Opening statements

Presentation of evidence by the petitioner Presentation of evidence by the defense

Rebuttal Closing statements

The investigator as a witness

Credibility Characteristics of a good investigator witness

Testifying on direct examination Testifying on cross-examination References

Chapter 17 Managing your caseload

References

Appendix 1: HIPAA privacy authorization form Appendix 2: Ambulance call report Appendix 3: Emergency department notes Appendix 4: Face sheet Appendix 5: Admission note—history and physical Appendix 6: Radiology note Appendix 7: Consult note Appendix 8: Informed consent for invasive, diagnostic, medical, and surgical procedures Appendix 9: Operative note Appendix 10: Anesthesia note Appendix 11: Physician orders Appendix 12: Progress note Appendix 13: Nursing notes Appendix 14: Medication administration record Appendix 15: Lab report Appendix 16: Discharge summary Appendix 17: Incident report Appendix 18: Evidence receipt and chain of custody Appendix 19: Peer review report Appendix 20: Prescription drug monitoring programs and contact information Appendix 21: Pharmacy data printout Appendix 22: Patient record review Appendix 23: State physician/professionals health programs Appendix 24: List of medicaid fraud control units Appendix 25: State insurance commissioner offices Appendix 26: Health insurance claim form Appendix 27: Superbill Appendix 28: Fraud worksheet Appendix 29: Initial physician application Appendix 30: State medical and osteopathic medical boards Appendix 31: Miscellaneous agency web addresses Index

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