Medical Records And The Law / Edition 4

Medical Records And The Law / Edition 4

ISBN-10:
0763734454
ISBN-13:
9780763734459
Pub. Date:
04/18/2006
Publisher:
Jones & Bartlett Learning
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Overview

Medical Records And The Law / Edition 4

Published in conjunction with the American Health Information Management Association (AHIMA), Medical Records and the Law is the ideal text for programs in HIM as well as a valuable reference for health and legal professionals. The Fourth Edition features an expanded discussion of state laws affecting the use and disclosure of health information and the substantial changes brought about by HIPAA and the growth of electronic health record systems. It also discusses the highly complex interplay of federal and state laws as well as the challenging area of how patient information may be used in connection with medical research involving human subjects.

Product Details

ISBN-13: 9780763734459
Publisher: Jones & Bartlett Learning
Publication date: 04/18/2006
Edition description: 4E
Pages: 591
Product dimensions: 9.10(w) x 6.10(h) x 1.40(d)

Table of Contents


Preface     xiii
Acknowledgments     xv
About the Authors     xvii
Introduction to the American Legal System     1
Chapter Objectives     1
Introduction     1
The Nature of Law     2
Sources of Law     3
The Constitution     3
Statutes     6
Decisions and Rules of Administrative Agencies     8
Court Decisions     9
Governmental Organization and Function     11
Organization of the Court System     13
State Court System     14
Federal Court System     15
Medical Records and Managed Care     19
Chapter Objectives     19
Introduction     19
Utilization Review     20
Managed Care     20
Managed Care Organizations and Related Entities     21
Health Maintenance Organizations     21
Preferred Provider Organizations     22
Independent Practice Associations     23
Group Practice Without Walls     23
Consolidated Medical Group     23
Physician/Hospital Organizations     24
Management Services Organizations     24
Foundation Model Integrated Delivery System     24
Physician Ownership Model Integrated Delivery System     25
Other Managed Care Organizations     25
The Impact of Managed Care on Health Information Management     26
HIPAA and State Privacy Rules     28
Changes in Medical Records Standards     30
Medical Records Requirements     31
Chapter Objectives     31
Records That Must Be Kept     31
The Legal Health Record     33
Content Requirements     35
Record Retention Requirements     40
Statutory and Regulatory Concerns     41
Statutes of Limitations     43
Medical Research and Storage Space Considerations     44
Association and Accreditation Agency Guidelines     46
Developing a Record Retention Policy     47
Destruction of the Record     48
Medical Records Entries     51
Chapter Objectives     51
Introduction     52
Legible and Complete Medical Records Entries     53
Timely Medical Records Entries     58
Authorship and Countersignatures     59
Authentication of Records     62
Auto-Authentication      66
Verbal Orders     68
Corrections and Alterations     69
Document Consent to Treatment     73
Chapter Objectives     73
Introduction     74
Legal Theories of Consent     76
Express and Implied Consent     76
Informed Consent     78
Exceptions to the Informed Consent Requirement     82
Distinguishing Informed Consent and HIPAA Authorization     85
Who Can Give Consent     86
Competent Adults     86
Incompetent Adults     87
Minors     89
Responsibility for Obtaining Consent     91
Documentation     94
Types of Consent Forms     95
Short Consent Forms     96
Long Consent Forms     96
Challenges to Consent Forms     97
Withdrawal of Consent     98
Impact of State Statutes     98
Impact of the Medicare Conditions of Participation     99
HIPAA Preemption     100
Access to Health Information     103
Chapter Objectives     103
Introduction     104
Types of Health Information     105
Protected Health Information     105
De-Identification of Health Information     106
Limited Data Set     109
Designated Record Set     111
Ownership of the Medical Record     111
Summary of Confidentiality Requirements     114
Federal Law     114
State Law     129
International Privacy Standards     139
Accreditation Organizations     140
HIPAA Covered Entities     141
Healthcare Providers     141
Healthcare Clearinghouses     142
Health Plans     143
Exercise of Professional Judgment     145
Minimum Necessary Rule     146
Hybrid Entities, Affiliated Covered Entities, and Organized Healthcare Arrangements     149
Hybrid Entities     149
Affiliated Covered Entities     151
Documentation of Designations     153
Organized Healthcare Arrangement     153
Uses and Disclosures of Medical Records Information     156
Access by or on Behalf of the Patient     157
Access, Uses, and Disclosures with the Patient's Authorization     164
Access by Family and Friends     170
Facility Directories     172
Records of Minors     173
Access for Treatment, Payment, or Healthcare Operations     177
Access by Employers     182
Mental Health Records     183
Alcohol and Drug Abuse Patient Records     187
Genetic Information     194
Record Duplication and Fees     196
QIO Record Keeping     199
QIO Access to Individual Patient Records     200
Third Party Access to Information Collected by a QIO     201
Patient Access to QIO Information     204
Utilization Review and Quality Assurance     205
Business Associates     208
Qualifying as a Business Associate     208
Requirements for Business Associate Agreements     213
Non-HIPAA Required Provisions for Business Associate Agreements     214
Liability for Acts or Omissions of Business Associates     217
Additional Patient Rights Under HIPAA     218
Right to Notice of How a Covered Entity Will Use and Disclose PHI     218
Right to Have Access to, Inspect, and Copy PHI     227
Right to Request Restrictions on the Uses and Disclosures of PHI for Treatment, Payment, and Healthcare Operations     227
Right to Request to Receive Confidential Communications     230
Right to Request Restrictions on the Uses and Disclosures for Which an Authorization Is Not Required     231
Right to Request an Amendment to PHI     231
Right to Receive an Accounting of Disclosures of PHI     235
Right to Report Violations of the Regulations to the Secretary of DHHS     238
Verifying Identity and Representations     239
HIPAA Administrative Requirements     242
Policies and Procedures     242
Documentation     242
Personnel     243
Training     243
Sanctions Imposed on Workforce     244
Duty to Mitigate     245
Safeguards     245
Reporting and Disclosure Requirements     247
Chapter Objectives     247
Introduction     247
Disclosures Required by Law     248
Child Abuse and Neglect     249
Abuse of Adults and Injuries to Disabled Persons     253
Controlled Drug Prescriptions and Abuse     255
Occupational Diseases     255
Abortion     256
Birth Defects and Other Conditions in Children     257
Cancer and Other Registries     258
Death or Injury from Use of a Medical Device     258
Communicable Diseases     259
Misadministration of Radioactive Materials     261
Death     261
Gunshot and Knife Wounds     262
Other Health Related Reporting Requirements     263
Required Disclosure by Managed Care Organizations     264
Health Oversight     265
Documentation and Disclosure: Special Areas of Concern     267
Chapter Objectives     267
Introduction     268
Special Documentation Concerns     269
Emergency Department Records     269
Celebrity Patients     275
Hostile Patients     277
Recording Indicators of Child or Elder Abuse or Domestic Violence     278
Patients Reusing Treatment and/or Near Death     278
Deceased Patients and Autopsy Authorizations     290
Recording Disagreements Among Professional Staff     291
Special Disclosure Concerns     292
Use and Disclosures for Marketing Purposes     292
Use and Disclosures for Fund-Raising     295
Records Sought by Managed Care Organizations     297
Records Sought by Parties to Adoption     300
Records Indicating Child or Elder Abuse     305
Health Information Sought by Law Enforcement Agencies     308
Warrants and Searches     313
Responding to Subpoenas and Court Orders     317
Fraud and Abuse Investigations     325
Oversight for HIPAA Compliance     327
Use of Outside Test Reports in Hospital Patients' Records     329
Licensure and Accreditation     329
Antitrust Issues     331
Change of Ownership or Closure: Disposition of Records     332
HIV/AIDS: Mandatory Reporting and Confidentiality     343
Chapter Objectives     343
Introduction     344
Duty to Report     345
Protecting Confidentiality of HIV-Related Information     348
The Privacy Rule and the Security Rule     348
State Law     349
Statutory Provisions Regarding Disclosure     351
Disclosures Permitted by the Privacy Rule     351
Disclosure to Third Parties with Patient Authorization     352
Disclosure to Healthcare Workers     352
Disclosure Without Consent to Emergency Medical Personnel     357
Disclosure Without Consent to Spouse or Needle-Sharing Partner     358
Other Permissible Disclosures Without Patient Authorization     362
Disclosure of Healthcare Provider's Status to Patients     363
Disclosure by Court Order     364
Liability for Unauthorized Disclosure of HIV-Related Information     367
Recommended Policies and Procedures     369
Discovery and Admissibility of Medical Records     373
Chapter Objectives     373
Introduction     373
Discoverability of Medical Records     374
Physician-Patient Privilege     376
Admissibility of Medical Records     383
Medical Records as Hearsay     383
Other Healthcare Documentation     386
Peer Review Records     387
Incident Reports     390
Legal Theories in Improper Disclosure Cases     395
Chapter Objectives     395
Introduction     395
HIPAA Liability     396
Violations     396
Other Statutory Bases for Liability     399
Theories of Liability     400
Defamation     400
Invasion of Privacy     406
Breach of Confidentiality     415
Risk Management and Quality Management     421
Chapter Objectives     421
Introduction     422
Increased Scrutiny of Medical Errors and Demand for Improving Quality Care     422
Relationship Between Risk Management and Quality Management     423
Risk Management     424
Quality Management     427
HIPAA and Risk Management/Quality Management     430
Compliance Programs     432
Medical Records in Risk Management, Quality Review, Compliance Activities, and Pay for Performance Initiatives     436
Electronic Health Records     439
Chapter Objectives     439
The Movement to Electronic Health Records     440
Electronic Health Records Systems     446
HIPAA Privacy Rule     450
Privacy Rule Issues for Interoperable Electronic Health Records     450
Other Privacy Issues     455
HIPAA Security Rule     456
General Security Requirements     458
Administrative Safeguards     461
Physical Security Standards     466
Technical Security Standards     469
Organizational Security Safeguards     471
Security Requirements in Health Data Networks     473
State Data Security Laws     474
Electronic Health Records Contracting Issues     475
Considerations for Contracting     475
Health Data Network Agreements     476
Vendor Agreements     477
Participation Agreements     478
Regulatory Issues     479
Antikickback Laws     479
Stark Law     481
Tax Laws Affecting Tax-Exempt Organizations     482
Antitrust     484
Electronic Health Records as Evidence     485
The Rule Against Hearsay     485
Best Evidence Rule     487
The Difficulties of E-Discovery     488
Professional Liability     490
Specific Electronic Health Records Security Issues     492
Facsimile Transmission of Health Information     492
Electronic Claims Processing: The Transactions Code Set Rule     495
Telemedical Records     498
Electronic Mail     499
Transmission of Health Information Through the Internet     506
Health Information in Medical Research     515
Chapter Objectives     515
Introduction     515
U.S. Federal Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research     517
The Common Rule     517
HIPAA Privacy Rule     521
Information Protected Under the Family Educational Rights and Privacy Act     527
Transitional Rule     527
Use of De-Identified Information and Limited Data Sets     528
Other Accommodations for Research in the HIPAA Privacy Rule     529
Certificates of Confidentiality     529
State Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research     531
State HIPAA Statutes     531
State Common Law     532
International Laws Relating to Medical Records and Clinical Trials     533
European Union (EU)     533
United Kingdom     536
Canada     537
Japan     538
Other Guidance     539
International Conference on Harmonisation     539
Conclusion     541
Glossary: Acronyms and Definitions     543
Index     561

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