Standard

 

HIT 192  MEDICAL RECORDS AND THE LAW

  

This course provides an introduction to the study of laws applicable to the health care field with emphasis in health information practices.  Topics include:  workings of the American Legal System, court systems and legal procedures, principles of liability, patient record requirements, access to health information, confidentiality and informed consent, the judicial process of health information, specialized patient records, risk management and quality assurance, HIV information, and computerized patient records.

 

Competency Areas

Hours

 

§         Workings of the American Legal System

§         Court systems and legal procedures

§         Principles of liability

§         Patient record requirements

§         Access to health information

§         Confidentiality and informed consent

§         The judicial process of health information

§         Specialized patient records

§         Risk management and quality assurance

§         HIV information

§         Computerized patient records

Class/Week – 3

Lab/Week – 0

Credit – 3

 

 

Prerequisite:  Provisional admission

 

Curriculum Guide

 

 

 

Competency

After completing this section, the student will:

Hours

Class Lab

WORKINGS OF THE AMERICAN LEGAL SYSTEM

 

Public and private law

 

 

 Sources of law

 

 

 Branches of government

 

 

 

 

 

 

Quasi-legal requirements

 

 

 

 

 

 

 

Differentiate between public and private law.

 

Identify and explain the differences between various sources of law.

 

Describe the branches of government and their roles in creating, administering, and enforcing the law.

 

Explain the process of how a bill becomes a law.

 

List and describe quasi-legal requirements to which health-care organizations are subject. 

 

   3       0

 

 

 

COURT SYSTEMS AND LEGAL PROCEDURES

 

 

Court systems

 

 

 

Compare and contrast subject matter jurisdiction between the federal and state court systems.

   3       0

 

 

 

 

 

 

 

 

 

Legal process

 

 

 

 

 

 

 

 

 

 

PRINCIPLES OF LIABILITY

 

Health-care liability

 

 

 

 

Theories of liability

 

 

 

 

 

 

 

 

 

 

 

 

 

Defenses and limitations on liability

 

Differentiate between subject matter jurisdiction and personal jurisdiction.

 

Explain the basic differences between a trial and an appeal.

 

Identify the steps in a civil lawsuit.

 

Distinguish between the different forms of discovery.

 

Describe the roles of the judge and the jury during a trial.

 

Compare and contrast an order of garnishment and writ of execution.

 

 

 

Describe each of the following relationships:  physician-patient, hospital-patient, and hospital-physician.

 

Define medical malpractice and negiligence.

 

Distinguish between the three types of damages.

 

Analyze the difference between negligence and res ipsa loquitar.

 

Describe each of the following intentional torts:  defamation, invasion of privacy, and medical abandonment.

 

Identify the defenses commonly raised in lawsuits involving health-care providers.

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   3       0

 

 

 

PATIENT RECORD REQUIREMENTS

 

Functions and uses of the medical record

 

Legal requirements for medical record content

 

 

 

 

 

 

 

 

 

Retention requirements 

 

 

Record destruction

 

 

 

 

 

 

 

 

 

 

 

ACCESS TO HEALTH INFORMATION

 

Ownership of health information

 

 

Access by or on behalf of the patient

 

 

 

 

 

 

 

 

Access by the researcher

 

 

 

 

Access pursuant to reporting laws

 

Access to adoption records

 

 

 

 

CONFIDENTIALITY AND INFORMED CONSENT

 

Confidentiality

 

 

 

 

 

 

 

 

 

Informed consent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JUDICIAL PROCESS OF HEALTH INFORMATION

 

Medical records as evidence

 

 

 

 

 

 

 

 

 

 

Responses to the legal process

 

 

 

 

 

 

 

 

 

 

 

 

SPECIALIZED PATIENT RECORDS

 

Drug and Alcohol Abuse

 

 

 

 

 

 

 

Mental health and developmental disability care

 

 

 

Home health care

 

 

 

RISK MANAGEMENT AND QUALITY ASSURANCE

 

Risk management

 

 

 

 

 

 

Quality assurance

 

 

 

 

 

 

 

HIV INFORMATION

 

Testing

 

 

Patient confidentiality

 

 

 

 

Legal challenges

 

 

 

COMPUTERIZED PATIENT RECORDS

 

Accreditation and licensure issues

 

 

 

 

 

 

 

Liability issues

 

 

 

Summarize the multiple functions and uses of a medical record.

 

Identify and explain how sources of law influence the content of the medical record.

 

Distinguish between authorship and authentication.

 

Differentiate between proper and improper methods for a health provider to correct the medical record.

 

Identify the factors influencing a record retention policy.

 

Compare and contrast record destruction done in the ordinary course with that done due to closure.

 

Identify the special procedures involved with the destruction of alcohol and drug abuse records upon a program’s closure.

 

 

 

 

 

 

Describe the continuum through which questions of health information ownership have passed.

 

List the common elements of a valid release of information form.

 

Explain who is granted authority to release health information.

 

Compare and contrast the rights of access of patients and third parties to patient-specific health information.

 

Explain the role that institutional review boards play in the access by researchers to health information regarding human subjects.

 

Describe the reasons and mechanisms for reporting public health threats.

 

Compare the judicial approach with the legislative approach for access to adoption records.

 

 

 

 

 

Explain the interrelationship between confidentiality and privacy.

 

Identify and discuss the three sources of law on which the right of privacy is based.

 

Explain the use and application of the physician-patient privilege.

 

List the obligations placed on health-care providers by the Patient Self-Determination Act.

 

Distinguish between living wills and durable powers of attorney for health care.

 

Discuss the legal protections afforded health-care providers when treating patients in an emergency situation.

 

Compare and contrast the professional disclosure standard and the reasonable patient standard.

 

 

 

 

Define the following legal terms associated with the role of a medical record in a lawsuit:  evidence, admissible, and hearsay.

 

Explain how the health information manager establishes the foundation and trustworthiness requirements for admitting the medical record into evidence.

 

Explain the use and application of the physician-patient privilege.

 

Discuss the differences between a subpoena, a subpoena ad testificandum, and a subpoena duces tecum.

 

Compare and contrast a court order authorizing disclosure of health information with a subpoena.

 

 

 

 

 

Summarize the difference between specialized patient records and general medical records.

Compare and contrast release of information forms used in an ordinary health-care setting with those used in a substance abuse setting.

 

Explain the difference between the official record and the personal record in the mental health/developmental disability context.

 

Identify the sources of legal requirements in the home health-care context.

 

 

 

 

Compare and contrast risk management with quality assurance.

 

Explain how the three components of patient record requirements relate to risk management.

 

Differentiate between the two aims of peer review statutes:  privilege and immunity.

 

Identify the reporting requirements of the Health Care Quality Improvement Act.

 

 

 

List the tests used to identify and/or confirm positive HIV results.

 

Describe the types of restrictions that confidentiality statutes and ethical guidelines place on HIV/AIDS information.

 

Analyze the limits on disclosure of HIV/AIDS information concerning the patient and the health-care provider.

 

 

 

 

Identify the reasons supporting the transformation to a computerized patient record.

 

Compare and contrast the three broad categories of law and regulation governing the creation and storage of a computerized patient record.

 

List the types of lawsuits that may arise from a breach of confidentiality of a computerized patient record.

 

Compare and contrast physical security, personnel security, and risk prevention techniques.

 

Evaluate risk prevention techniques associated with computerized patient record systems.

 

 

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Suggested Resources

 

 

Suggested Resources include textbooks shown below or most current edition.

 

McWay, Dana C.  (1997).  Legal Aspects of Health Information Management.  Albany:  Delmar .