•What is the Patient Self-Determination Act. How do you think records management procedures have had to respond to this piece of legislation?

The Patient Self-Determination Act (PSDA) is a U.S. federal law that was enacted in 1990. Its primary purpose is to ensure that individuals have the right to make decisions about their own medical treatment and to have their wishes honored, even if they are unable to communicate those wishes at the time.

Under the PSDA, healthcare providers who participate in Medicare and Medicaid are required to inform patients about their rights to make decisions regarding their care, including the right to accept or refuse medical treatment. They must also inform patients about their rights to create advance directives, such as living wills or durable power of attorney for healthcare, which enable individuals to express their wishes regarding treatment decisions in advance.

In terms of records management procedures, healthcare organizations have had to respond to the PSDA by implementing systems to document and maintain patients' advance directives. This typically involves creating clear policies and procedures that guide healthcare workers in identifying and documenting patients' advance directives, and ensuring that these directives are readily accessible and honored during the course of treatment.

To comply with the PSDA, healthcare providers may incorporate specific changes in their records management practices, such as:

1. Documentation: Implementing forms or electronic systems to document patients' advance directives, including living wills and durable power of attorney for healthcare. These documents should be stored securely to ensure easy retrieval when needed.

2. Education and Training: Offering training programs to educate healthcare staff on the importance of the PSDA, patients' rights, and the proper procedures for documenting and managing advance directives. This helps ensure uniformity in the implementation of records management procedures.

3. Communication: Establishing effective communication channels to regularly inform patients about their rights under the PSDA, the importance of advance directives, and how their wishes will be honored within the healthcare system.

4. Integration with Electronic Health Records (EHRs): Integrating advance directives into electronic health records systems to make them easily accessible to healthcare providers across different settings. This allows for immediate awareness of patients' wishes, even in emergency situations.

5. Compliance Monitoring: Regularly reviewing and auditing records management procedures to ensure compliance with the PSDA. This may include conducting internal audits, implementing quality control measures, and performing periodic reviews to identify and address any deficiencies.

By implementing these changes, healthcare organizations seek to ensure that patients' rights are respected, their wishes are honored, and their advance directives are effectively managed within the records management framework.