Author: William Roach, Jr., MS, JD, Robert Hoban, JD, Bernadette Broccolo, JD, Andrew Roth, JD, Timothy Blanchard, MHA, JD
Publisher: Jones & Bartlett Learning
Publication Date: 2006
ISBN 10: 0763734454
ISBN 13: 9780763734459
Edition: 4th


Published in conjunction with the American Health Information Management Association (AHIMA), the Fourth Edition of Medical Records and the Law is once again the ideal text for programs in HIM as well as a valuable reference resource for health professionals and those in the legal profession. Providing a useful resource to those in the legal profession, it addresses the substantial changes brought about by HIPAA and the growth of electronic health record systems and electronic data networks, retaining and updating the discussion of state laws affecting the use and disclosure of health information. This book also discusses the highly complex interplay of federal and state health information privacy laws.

Table of Contents

Front Matter

  • Note
  • Preface
  • Acknowledgments
  • About the Authors

Introduction to the American Legal System

  • Introduction
  • The Nature of Law
  • Sources of Law
  • Governmental Organization and Function
  • Organization of the Court System

Medical Records and Managed Care

  • Introduction
  • Utilization Review
  • Managed Care
  • Managed Care Organizations and Related Entities
  • The Impact of Managed Care on Health Information Management

Medical Records Requirements

  • Records That Must Be Kept
  • The Legal Health Record
  • Content Requirements
  • Record Retention Requirements
  • Destruction of the Record

Medical Records Entries

  • Introduction
  • Legible and Complete Medical Records Entries
  • Timely Medical Records Entries
  • Authorship and Countersignatures
  • Authentication of Records
  • Verbal Orders
  • Corrections and Alterations

Document Consent to Treatment

  • Introduction
  • Legal Theories of Consent
  • Distinguishing Informed Consent and HIPAA Authorization
  • Who Can Give Consent
  • Responsibility for Obtaining Consent
  • Documentation
  • Types of Consent Forms

Access to Health Information

  • Introduction
  • Types of Health Information
  • Ownership of the Medical Record
  • Summary of Confidentiality Requirements
  • HIPAA Covered Entities
  • Exercise of Professional Judgment
  • Minimum Necessary Rule
  • Hybrid Entities, Affiliated Covered Entities, and Organized Healthcare Arrangements
  • Uses and Disclosures of Medical Records Information
  • Record Duplication and Fees
  • QIO Record Keeping
  • Utilization Review and Quality Assurance
  • Business Associates
  • Additional Patient Rights Under HIPAA
  • Verifying Identity and Representations
  • HIPAA Administrative Requirements

Reporting and Disclosure Requirements

  • Introduction
  • Disclosures Required by Law
  • Other Health Related Reporting Requirements

Documentation and Disclosure: Special Areas of Concern

  • Introduction
  • Special Documentation Concerns
  • Special Disclosure Concerns

HIV/AIDS: Mandatory Reporting and Confidentiality

  • Introduction
  • Duty to Report
  • Protecting Confidentiality of HIV-Related Information
  • Statutory Provisions Regarding Disclosure
  • Recommended Policies and Procedures

Discovery and Admissibility of Medical Records

  • Introduction
  • Discoverability of Medical Records
  • Admissibility of Medical Records
  • Other Healthcare Documentation

Legal Theories in Improper Disclosure Cases

  • Introduction
  • HIPAA Liability
  • Other Statutory Bases for Liability
  • Theories of Liability

Risk Management and Quality Management

  • Introduction
  • Increased Scrutiny of Medical Errors and Demand for Improving Quality Care
  • Relationship Between Risk Management and Quality Management
  • Risk Management
  • Quality Management
  • HIPAA and Risk Management/Quality Management
  • Compliance Programs
  • Medical Records in Risk Management, Quality Review, Compliance Activities, and Pay for Performance Initiatives

Electronic Health Records

  • The Movement to Electronic Health Records
  • HIPAA Privacy Rule
  • HIPAA Security Rule
  • State Data Security Laws
  • Electronic Health Records Contracting Issues
  • Regulatory Issues
  • Electronic Health Records as Evidence
  • Professional Liability
  • Specific Electronic Health Records Security Issues

Health Information in Medical Research

  • Introduction
  • U.S. Federal Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
  • State Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
  • International Laws Relating to Medical Records and Clinical Trials
  • Other Guidance

APPENDIX A Glossary: Acronyms and Definitions