School of Health Sciences Unit 3 Legal Aspects of Health Information and Health Care Statistics HI 135 Instructor: Alisa Hayes, MSA, RHIA, CCRC

Introduction Instructor Alisa Hayes, MSA, RHIA, CCRC Contact Information AIM:AlisaCHayes Office Hours By appointment School of Health Science

Chapter 3 Judicial Process of Health Information Health records serve multiple purposes: Supporting direct patient care Quality improvement efforts Public health monitoring Billing and reimbursement A legal document recording a patient care episode Disclosure of health information requires patient permission or legal mandate School of Health Science

Chapter 3 Judicial Process of Health Information In a lawsuit, evidence is presented to prove or disprove claims: Testimony, writings, objects/things Health record To be used, evidence must be admissible: Pertinent and proper Relevant to the matter Determined by the judge in accordance with established rules of evidence School of Health Science

Chapter 3 Judicial Process of Health Information Role of HI Manager may be called to testify as to foundation and trustworthiness Must possess knowledge of and testify to: Requirements to create and keep records Policies and procedures governing access to records Quality control methods such as how corrections are made If EHR, there are additional steps School of Health Science

Chapter 3 Judicial Process of Health Information Health record ownership Health care provider owns the medium in which the information is stored (i.e., the chart) Patient has a property interest in that information Provider is responsible for control and safekeeping of record Release of record must be in accord with proper legal process Authorization of patient Court processes: subpoena, court order, or discovery request School of Health Science

Chapter 3 Judicial Process of Health Information Subpoena- A command from a court or other authorized official Court Orders- Authorizes disclosure that would otherwise be prohibited by statute or regulation School of Health Science

Chapter 3 Judicial Process of Health Information Requests for health information may be made during the discovery process Electronic Health Record is considered ESI (Electronically Stored Information) Do not assume that every discovery request or subpoena is proper or valid Improper release or protected health information may subject provider to liability Never ignore a discovery request, subpoena, or court order Failure to respond may result in fines. School of Health Science

Chapter 12 Risk Management HIM role involves participation in non-patient record keeping issues as well Risk management Quality management Utilization management School of Health Science

Chapter 12 Risk Management Risk management function varies by institution May report to finance, operations, or safety Often works with in-house counsel HIM has important role Enforcing patient record requirements Use of incident reports School of Health Science

Chapter 12 Risk Management Security of Health Information Availability of records for patient care Necessary for timely, accurate communication Health care providers depend on record to make care decisions Access to health information by patients Ensure staff is trained to respond to requests Release made only to one with right to access Retention of records Compliance with state and federal laws Negligent loss or premature destruction creates risk of lawsuit School of Health Science

Chapter 12 Risk Management Incident report-risk management technique used to describe and manage adverse events Hospital incident is Any event or circumstance that is not consistent with normal operations and routine care Errors, accidents, situations that could have or did result in injury or damage to a person or property Medication errors, slip and fall, loss of belongings, equipment malfunction Incident report documents adverse event HIM role: make sure that report is not placed in health record School of Health Science

Current Week 4/4/12-4/10/12 Complete Reading (ch 3 and 12 (pp ) Discussion participation Learning Activity: select case at end of ch 1,2 or 4 and respond to question at end of case study Test 1- Study guide available in docsharing School of Health Science

Next Week 4/11/11-4/17/11 Unit 4: chapter 9 (pp ) Selection of research topic for paper due in unit 9 Confidentiality response paper ANY QUESTIONS??? FYI: UNIT 5 seminar on Thursday 4/19 one time change to 8pm EST School of Health Science