Professional Practice, Health Promotion and Disease Prevention · 7 min read
Legal and Ethical Practice
This chapter covers privacy, informed consent and decision-making capacity, care of minors, mandatory reporting, malpractice, core ethical principles, and the communication skills (cultural humility, health literacy, interpreters) that make consent meaningful.
HIPAA Privacy
The HIPAA Privacy Rule protects individually identifiable health information. Disclosure without written authorization is permitted for treatment, payment and health care operations, and for specific public-interest purposes:
Reports of abuse, neglect or domestic violence as required by law.
Court orders, and limited law enforcement and judicial requests.
To prevent a serious and imminent threat to the health or safety of a person or the public.
Health oversight activities, organ donation, and workers' compensation as allowed.
Other key rules: use the minimum necessary information; patients have a right to access and obtain copies of their records (generally within 30 days) and to request amendments; providers may share information with family members involved in care when the patient is present and does not object, or when the patient is incapacitated and sharing is in the patient's best interest. Psychotherapy notes have extra protection, and federal rules (42 CFR Part 2) add protection for substance use disorder treatment records.
Common Trap: An adult daughter calls asking for her competent father's test results. Without his permission, the NP should not disclose them. The best response is to ask the patient whether he wants information shared, and document his choice.
Informed Consent, Capacity and Competence
Valid informed consent requires disclosure (diagnosis, nature and purpose of the intervention, risks, benefits, alternatives including no treatment), understanding, voluntariness and decision-making capacity. The clinician performing the procedure obtains consent; signing a form documents, but does not replace, the discussion. Emergency treatment to prevent death or serious harm may proceed under implied consent when no surrogate is available.
Capacity vs Competence
| Feature | Capacity | Competence |
|---|---|---|
| Type of determination | Clinical | Legal |
| Who decides | Any treating clinician, including the NP | A judge |
| Scope | Decision-specific and can fluctuate | Global; changed only by the court |
| Result if absent | Surrogate decides | Court appoints a guardian |
Capacity has four elements: the patient can communicate a choice, understand the relevant information, appreciate how it applies to their own situation, and reason about options consistently with their values. Capacity is decision-specific: a patient with mild dementia may lack capacity for a complex surgery decision yet retain capacity to name a health care proxy. A diagnosis of dementia, a psychiatric illness or a choice the clinician disagrees with does not by itself mean incapacity.
Clinical Pearl: Reassess capacity after treating reversible causes such as delirium, hypoglycemia, hypoxia or intoxication. The higher the risk of the decision, the more rigorous the assessment should be.
Minors, Emancipation and Assent
In general, a parent or guardian consents for patients under 18. Exceptions:
Emancipated minors (by court order, marriage, military service, or financial independence living apart from parents, depending on state law) consent for themselves.
Many states recognize a mature minor doctrine for specific decisions.
All states allow minors to consent to STI testing and treatment; most allow confidential contraception, prenatal care, and outpatient substance use and mental health care, with details varying by state.
Pregnancy alone does not emancipate a minor in every state, though it often allows consent for pregnancy-related care.
Assent is the agreement of a child or adolescent who cannot give legal consent; seek it along with parental permission. Interview adolescents alone for part of each visit, explain confidentiality and its limits (risk of serious harm to self or others, abuse), and use the HEADSSS framework (home, education/employment, activities, drugs, sexuality, suicide/depression, safety). Remember that insurance explanation-of-benefits statements can unintentionally reveal confidential services to parents.
Case Snapshot: A 16-year-old comes alone to a community health clinic requesting chlamydia testing and contraception and asks that her parents not be told. The NP provides testing and contraceptive counseling confidentially and discusses how billing might reveal the visit. This is correct because all states allow minors to consent to STI care, and most allow confidential contraception, so parental consent is not required.
Mandatory Reporting
Other state-specific duties may include gunshot wounds and medical conditions affecting driving.
Exam Tip: A competent adult who discloses partner violence and refuses a shelter referral keeps the right to decide. The best answer is safety planning, documentation and resources, unless state law mandates a report for a specific injury.
Malpractice
Malpractice is professional negligence. The plaintiff must prove four elements:
NPs are held to the NP standard of care and are personally liable for their own practice even when employed or collaborating. Risk reduction: timely, objective documentation; closing the loop on test results and referrals; informed consent and informed refusal documentation; clear communication; and practicing within scope. Never alter a record after the fact; add a dated late entry instead.
Ethical Principles
Core Ethical Principles
| Principle | Meaning | Primary care example |
|---|---|---|
| Autonomy | Respect for self-determination | Honoring an informed refusal of dialysis |
| Beneficence | Act for the patient's good | Recommending indicated vaccines |
| Nonmaleficence | Avoid harm | Deprescribing a benzodiazepine in a patient who falls |
| Justice | Fair distribution of resources | Same care regardless of insurance |
| Fidelity | Keeping promises and commitments | Following up on results as promised |
| Veracity | Truthfulness | Disclosing a medication error |
The principle of double effect allows an action with a good intended effect (relief of suffering with opioids) even if a foreseen but unintended harmful effect may occur. Paternalism, overriding a capable patient's wishes "for their own good," conflicts with autonomy. Advocacy means supporting the patient's own goals, including connecting them with resources.
Cultural Humility, Health Literacy and Interpreters
Cultural humility is a lifelong process of self-reflection and learning from each patient, rather than assuming knowledge of a group's beliefs. Ask about the patient's own explanation of illness, preferences for family involvement and use of traditional remedies.
Limited health literacy is common and is not detected by education level or appearance. Strategies:
Teach-back: ask the patient to explain or demonstrate in their own words ("To make sure I explained clearly, how will you take this insulin?"). It checks the clinician's teaching, not the patient's intelligence.
Plain language, 2-3 key points per visit, chunk-and-check, pictures and demonstration.
Written materials at about a 5th-6th grade reading level.
For patients with limited English proficiency, federal law (Title VI of the Civil Rights Act and the ACA nondiscrimination provisions) requires meaningful language access. Use a qualified medical interpreter (in person, video or phone). Avoid family members, and never use minor children, to interpret except in an emergency until a professional is available. Speak directly to the patient in short segments.
Common Trap: The patient's bilingual adult son offers to interpret a new cancer diagnosis discussion. The best choice is still a professional interpreter, because family interpreters omit, filter and soften information and compromise confidentiality.
Social Determinants of Health
Social determinants of health (SDOH) are the conditions in which people are born, live, learn, work and age. Healthy People groups them into five domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. Screen for food insecurity (for example the two-item Hunger Vital Sign), housing instability, transportation, utilities, interpersonal safety and social isolation, then connect patients with resources. Address cost barriers when prescribing (generic options, patient assistance) and consider SDOH when an adherence problem is really an access problem.
Key Takeaways
HIPAA permits disclosure without authorization for treatment, payment, operations, public health reporting, abuse reporting and imminent threats; otherwise ask the patient.
Capacity is a clinical, decision-specific judgment the NP can make; competence is a legal determination made by a court.
Minors can consent to STI care in all states; emancipated minors consent for themselves; seek assent from younger patients.
Report suspected child and elder abuse (suspicion is enough); IPV reporting for competent adults varies by state.
Malpractice requires duty, breach, causation and damages.
Use teach-back for health literacy and qualified medical interpreters, not family members.
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