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Doody's Review ServiceReviewer: Jay Gold, MD, JD, MPH (MetaStar, Inc.)
Description: This book is a presentation of the law regarding medical records, including the latest trends in health information management. This is a revision of the 1994 edition.
Purpose: The purpose is to analyze the legal issues affecting health information management. This is a very important issue today, with technological advances creating all sorts of scenarios in recordkeeping that would not have been possible in the past.
Audience: This book is intended for attorneys and healthcare providers. It should be useful to both — the author avoids arcane legal terminology, while there are enough references to statutory and case law to make it useful for lawyers. The author is a practicing attorney.
Features: After an introduction to the American legal system, the author covers a myriad of topics related to the subject: medical record entries, managed care issues, consent to treatment, access, confidentiality, reporting, disclosure, documentation, legal admissibility of records, improper disclosure, risk management and quality review, and computerized medical records. There is a separate chapter on HIV issues. The references are excellent, and the index is good.
Assessment: The law in this area changes very quickly: telemedicine, e-mail, electronic claims processing, and many other topics must now be added to the traditional law of medical records. With this book the author offers a creditable exposition of the law in the area.