1. Health Information Management Technology: An Applied Approach
Chapter 8 Health Law

2. Basic Legal Concepts How are laws classified? Sources of law:
Public law
Private law
Sources of law:
Constitutions
Statutes
Administrative law
Judicial decisions

3. US Legal System How are legal disputes handled? US court system
District courts
Courts of appeals
Supreme Court
State court systems
Trial courts
Appellate courts
State supreme court

4. US Legal System How are legal disputes handled? (continued)
Dispute resolution
Arbitration
Mediation

5. US Legal Process Bringing a lawsuit
Plaintiff(s): summons and complaint
Defendant(s)
Counterclaim
Joinder
Crossclaim

6. US Legal Process Discovery period Trial
Discovery tools:
Deposition
Subpoena
Subpoena ad testificandum
Subpoena duces tecum
Trial
Post-trial: appeal and collection of the judgment

7. Medical Malpractice Professional liability causes of action:
Breach of contract
Tort
Intentional tort
Negligence
Medical malpractice refers to professional liability of healthcare providers

8. Physician-Patient Relationship
Physician-patient relationship is based on a contract
Express
Implied
Cause of action is breach of contract

9. Medical Malpractice Stemming From Negligence Torts
Types of negligence
Nonfeasance
Malfeasance
Misfeasance
Elements of negligence
Duty to meet a standard of care
Breach
Causation
Injury or Harm

10. Patient Rights and Healthcare Decisions
Consent
General consent
Informed consent
Advance directives
Durable power of attorney for healthcare decisions
Living will
Do-not-resuscitate order (DNR)

11. Legal Issues in Health Information Management
Compilation and maintenance of health records
Ownership and control of health records, including use and disclosure
Defining the legal health record

12. Compilation and Maintenance of the Health Record
What requirements affect the form and content of the health record?
Statutory laws such as state and federal statutes
Regulatory laws such as Medicare
Standards by accrediting bodies such as Joint Commission
Third-party payer requirements
Failure to comply will likely result in some type of penalty

13. Compilation and Maintenance of the Health Record
Guidelines for complying with requirements:
Policies and procedures should comply with all laws and standards
Health records should be systematically organized
Only authorized persons should document in the health record
Policies should specify who can receive and transcribe verbal orders

14. Compilation and Maintenance of the Health Record
Guidelines for complying with requirements (continued):
Health record entries should be documented at the time service is provided
Authors of all entries should be clearly identified
Only approved abbreviations and symbols should be used in the health record
Prohibited abbreviations
All entries should be permanent

15. Compilation and Maintenance of the Health Record
Guidelines for complying with requirements (continued):
Policies and procedures for error correction should be in place
Policies and procedures for addenda to the record should be in place

16. Ownership and Control of the Health Record
The health record is owned by the organization that created and maintains it
Control of the record includes its use and disclosure
Individuals have a right to access their own information, with some exceptions

17. State Laws Involving Use and Disclosure
Privileged communication statutes
Protect information shared as part of the physician-patient relationship
State laws may specifically provide patients with the right of access (in compliance with HIPAA)
State laws may require disclosure without patient authorization
Examples: vital statistics; public safety

18. Health Information in Judicial Proceedings
Health records are usually admissible in litigation or judicial proceedings
Authentication affirms a record’s legitimacy

19. Legal Health Record
Is the official business record created by or for a healthcare organization
Is the record that will be disclosed upon a valid request by third parties
Must be distinguished from Electronic Health Records (EHRs), Designated Record Set (DRS), and Personal Health Records (PHRs)

20. Legal Health Record
Organizations should inventory all documents and data that could comprise the legal health record, considering all locations
Electronic documents that may be part of the legal health record include: s
Diagnostic images and electronic fetal monitoring strips
Digital photography and video

21. Retention of Health Records
When developing retention policies, consider:
Applicable federal and state statutes and regulations
Statutes of limitation for malpractice and other claims
Accreditation standards
Operational needs of the organization

22. AHIMA Retention Guidelines
Ensure that patient information is available to meet patient care needs, legal requirements, research, education, and other legitimate uses
Develop a retention schedule that meets needs of patients, physicians, researchers, and other legitimate users and complies with all regulations and laws

23. AHIMA Retention Guidelines (continued)
Develop guidelines that specify what information should be retained, the retention period, and the storage medium
Clearly specify the destruction method to be used for each medium

24. Record Destruction Must take into account
Applicable federal and state statutes and regulations
Accreditation standards
Pending or ongoing litigation, investigations, or audits
Storage capabilities
Cost

25. Record Destruction
Destruction may be performed by the organization that owns the records, or it may be outsourced
Documentation:
Certificate of destruction or manner of destruction
List of all destroyed records
Agreement that assures protection of the information

26. Record Destruction Considerations for Electronic Information
The information must be actually destroyed rather than merely deleting the pathway to access it
The likelihood of duplicate records remaining in circulation is greater with electronic records

27. Medical Staff Appointments and Privileges
Facility is responsible to establish policies and procedures to ensure reasonable care in medical staff appointments
Credentialing for appointment and reappointment
Clinical privileges to define the set of services a physician is permitted to perform
National Practitioner Data Bank formed by the Health Care Quality Improvement Act of 1986

28. Licensure, Certification, and Accreditation
Licensure: allows an individual to practice, or an organization to operate
Certification
Individuals: designation of competence by a private organization
Healthcare organizations: designation by US Department of Health and Human Services that its Conditions of Participation have been met
Accreditation: designation of excellence by a private entity