Legal and regulatory requirements

CCMC Glossy of Terms Related to Legal and Regulatory Requirements

Discovery: The process by which one party to a civil suit can find out about matters that are relevant to his/her case, including information about what evidence the other side has, what witnesses will be called upon, and so on. Discovery devices for obtaining testimony, requests for documents or other tangibles, or requests for physical or mental examinations.

Informed Consent: Consent given by a patient, next of kin, legal guardian, or designated person for a kind of intervention, treatment, or service after the provision of sufficient information by the provider. A decision based on knowledge of the advantages and disadvantages and implications of choosing a particular course of action. 

Malpractice: Improper care or treatment by a healthcare professional. A wrongful conduct.

Negligence: Failure to act as a reasonable person. Behavior is contrary to that of any ordinary person facing similar circumstances.

Respondeat Superior: Literally, “let the master respond.” This maxim means that an employer is liable in certain cases for the wrongful acts of his/her employees, and the principal for those of his/her agency.
Statute: An act of a legislature declaring, commanding, or prohibiting and action, in contrast to unwritten common law.

Subpoena: A process commanding a witness to appear and give testimony in court. 

Tort: A civil wrong for which a private individual may recover money damages, arising from a breach of duty created by law.

Other Important Definitions

Patient Abandonment-terminating the relationship with the patient without giving reasonable notice or providing a competent replacement resulting in lack of necessary medical care.

Legal and Regulatory Requirements Important to the Case Manager

Even though case managers may not be providing direct patient care, this does not shield them from the risk of malpractice. The most frequent reason given for filing a malpractice claim is when the patient feels the provider was discourteous and did not take time with the patient to listen or explain. This comes down to the basics of communication. When a patient feels the provider has listened to them, understands their situation and has been respectful of their needs, they are very unlikely to seek legal action.

Informed Consent

The following criteria must be met for consent to be informed:

  • A discussion of possible side effects, risks, consequences, and benefits of treatment, medication or procedures, including consequences or risks of stoppage of the service.
  • The client must have the capacity to make clear, competent decisions.
  • Consent must be self determined; not coerced or pressured by the agency or provider of services.
  • Information must be clear and easy to understand.
  • Information must be given verbally and in writing.
  • The patient must have an opportunity for questions and answers.

Interstate Compact for Nursing

Licensing can be a problem for Case Managers who provided case management for patients who reside in a state where the Case Manager is not licensed. This can often be the case for Case Managers who manage their clients via the telephone. 

The Nurse Licensure Compact gives nurses the ability to practice nursing across state lines. The nurse must be licensed in her state of residency. If that state is a compact state, she can then practice in another state that is also in the compact.

Negligent Referral

A negligent referral is a referral of a patient to a provider who is known to be unqualified. Even if the case manager is unaware that the provider is unqualified, they can still be held liable. This is because it is expected that a reasonably prudent case manager would make sure the healthcare provider they are referring to is professionally qualified and without physical or mental impairment that could result in harm to the patient.

Principal/Agent Relationship

The agent is the one who is authorized to act for another person or entity (the Principal). This is the case where the case manager works for her employer, or a doctor works for a hospital. In these cases the principal (employer/hospital) is responsible for the acts of the agent.