Description
Overview
In this module, we introduce the student to fundamental concepts related to the US legal system.
MODULE INTRODUCTION
The chapter includes a discussion of the types and sources of law, as well as the court system and the trial process. Also discussed are professional liability and individual rights, with a focus on advance directives. The second part of the chapter focuses on the health record itself: ownership, control, and maintenance of the health record; use and disclosure of health information; and destruction of the health record. The chapter includes a discussion of medical staff credentialing. Although it is generally not a significant percentage of HIT professional practice, HIT professionals should be familiar with how it works. The chapter concludes with an overview of the general concepts of licensure, certification, and accreditation.
The topic items that follow are required for completing this module:
Discussion 8.1: Privileged Communication [1b, 3a, 3b, 3c, 3d]
Lab Assignment 8.1: The Legal Health Record [1b, 3a, 3b, 3c, 3d]
SPC Real World Case 8.1: Medical Malpractice [1b, 3a, 3b, 3c, 3d]
SPC Real World Case 8.2: California Senate Bill 1415 [1b, 3a, 3b, 3c, 3d]
Dropbox 8.1: Lab Assignment 8.2: Record Retention Standards [1b, 3a, 3b, 3c, 3d]
Privileged Communication15 POINTS
Privileged communication is a frequent topic in healthcare these days.
For this discussion, you will answer the following questions in your post:
What is privileged communication?
What role does HIPAA play in an individual’s right to access his/her health information when access is denied?
For this discussion, read Chapter 8 and research the internet to gather information.
Guidelines
Please make sure your discussion posts include all of the items below:
What is privileged communication?
What role does HIPAA play in an individual’s right to access his/her health information when access is denied?
Note: your initial summary post should be one or two paragraphs in length (a paragraph is at least 3 sentences in length).
Real World Case 8.1: Medical Malpractice20 POINTSFor this activity, you will review the Real World Case 8.1 on page 211 of your textbook. You will conduct an analysis of the situation and summarize how you would have addressed the issues.
This case highlights the fact that healthcare professionals in addition to physicians are subject to professional malpractice liability. Medical malpractice is usually associated with professional liability. To be considered medical malpractice under the law, the claim must include the following characteristics; there was a violation of the standard of care, an injury occurred due to negligence and the injury resulted in significant damages. Examples include: misdiagnoses, unnecessary surgery, error in medication dosage or poor follow up care.
Analyze Real World Case 8.1. For this assignment, you will conduct an analysis on a lawsuit filed against a physical therapist and reflect on where it fits within the guidelines of a malpractice suit.
Why do you think physicians are most frequently linked with the term “medical malpractice?”
Of the three types of negligence, which type do you think most closely describes a physical therapist who acted too aggressively?
Why it is likely that a much larger award would have been rendered at trial than through settlement?
Guidelines
Before you submit your Real-World Case Study written responses:
Ensure all of the Real World Case Study 8.1 questions are answered thoroughly.
View the Critical Thinking Assignment Rubric (20 points) for the grading criteria.
Real World Case 8.2: California Senate Bill 141520 POINTS
For this activity, you will review the Real World Case 8.2. You will conduct an analysis of the situation and summarize how you would have addressed the issues.
Analyze Real World Case 8.2. For this assignment, you will conduct an analysis on a lawsuit filed against a physical therapist and reflect on where it fits within the guidelines of a malpractice suit.
What is your opinion of California Senate Bill 1415? Do you think patients should be made aware of an organization’s record retention period, although this has not been industry practice? Why or why not?
A patient requested a copy of their health record and learned that it had been destroyed. The patient complains to the state health department because they were not notified that their record would be destroyed. What response would you expect from the state health department?
Do you believe healthcare facilities should destroy health records? Justify your choice.
Guidelines
Before you submit your Real-World Case Study written responses:
Ensure all of the Real World Case Study 8.2 questions are answered thoroughly.
View the Critical Thinking Assignment Rubric (20 points) for the grading criteria.
Then, finally, complete and submit your answers in the Quiz Tool.
Lab Assignment 8.2: Record Retention Standards 15 POINTSThe HIM professional must take into consideration multiple factors when developing health record retention policies. These factors include applicable federal and state statutes and regulations, accrediting standards, and operational needs of the facility. AHIMA retention recommendations are designed to meet not only the legal aspects of the health record but the needs of the patient and the facility.
Instructions:
Review the AHIMA record retention standards which can be found in table 8.4 page 238 in your textbook.
For this assignment, you will create a grid to show the recommended retention periods for the following items:
Diagnostic images
Disease Index/Physician Index
Fetal heart monitor records
Master patient/person index
Operative index
Patient health records
Register of births/deaths
Register of surgical procedures.
Your document should also include your response to the following question:
Why do you think AHIMA established these recommended retention periods?Health Information Management Technology: An
Applied Approach
Sixth Edition
Chapter 8: Health Law
ahima.org
ahima.org
© 2020 AHIMA
© 2019
© 2020 American Health Information Management Association
Basic Legal Concepts
How are laws classified?
• Public law versus private law
• Criminal law versus civil law
Sources of law:
• Constitutions
• Statutes
• Administrative law
• Judicial decisions
ahima.org
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© 2019
US Legal System
1
How are legal disputes handled?
• US court system
• District courts
• Circuit courts
• Supreme Court
• State court systems
• Trial courts (limited or general jurisdiction)
• Courts of appeal/appellate courts
• State supreme court
ahima.org
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© 2019
US Legal System
2
How are legal disputes handled? (continued)
• Dispute resolution
• Arbitration
• Mediation
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US Legal Process
1
Bringing a lawsuit
• Plaintiff(s): summons and complaint
• Defendant(s)
• Counterclaim
• Joinder
• Crossclaim
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US Legal Process
2
Discovery (pretrial)
• Discovery methods
• Deposition
• Interrogatories
• Requests for production (documents or other pertinent items)
• Discovery tools (to compel receipt of information)
• Subpoena
• Subpoena ad testificandum or subpoena duces tecum with authorization
• Court order
• Warrant
ahima.org
© 2020 AHIMA
© 2019
E-Discovery
Parties obtain and review electronically stored data
Governed in federal court by the Federal Rules of Civil Procedure
Considerations
• Discoverable data
• Metadata
• Legal hold
• Spoliation
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US Legal Process
3
Trial
• Jury or bench trial
• Admissibility of evidence is considered
Post-trial
• Collection of judgment (civil) or sentencing (criminal)
• Possibly appeals
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Evidence
1
Federal Rules of Evidence govern admissibility in federal courts
• Hearsay: out-of-court statement used to prove the truth of the matter
• Not admissible unless it meets an exception
• Health records often admitted through the business records exception to the hearsay rule
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© 2019
Evidence
2
• Hearsay
• Business records exception
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© 2019
Medical Malpractice
Professional liability causes of action:
• Breach of contract
• Tort
• Intentional tort
• Negligence
Medical malpractice refers to professional liability of healthcare
providers
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Physician-Patient Relationship
Physician-patient relationship is based on a contract
• Express
• Implied
Cause of action is breach of contract
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Professional Liability
• Breach of contract
• Tort
• Intentional tort
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Medical Malpractice Stemming From Negligence Torts
Types of negligence
Elements of negligence
• Nonfeasance
• Malfeasance
• Misfeasance
• Duty to meet a standard of care
• Breach
• Causation
• Injury or harm
ahima.org
© 2020 AHIMA
© 2019
Patient Rights Regarding Healthcare Decisions
Consent
• General consent
• Informed consent
Advance directives
• Durable power of attorney for healthcare decisions (D P O A-HCD)
• Living will
• Do-not-resuscitate (DNR) order
ahima.org
© 2020 AHIMA
© 2019
Legal Issues in Health Information Management
• Creation and maintenance of health records
• Ownership and control of health records, including use and
disclosure
• The legal health record including content, retention and
destruction
ahima.org
© 2020 AHIMA
© 2019
Creation and Maintenance of the Health Record
1
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
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© 2020 AHIMA
© 2019
Creation and Maintenance of the Health Record
2
Guidelines for complying with requirements should address issues
such as:
• Record content and format
• Entries and authentication
• Authorship
• Language and terminology
• Receipt and transcription of verbal orders
• Documentation errors and amendments
• Analysis of documentation
ahima.org
© 2020 AHIMA
© 2019
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
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© 2020 AHIMA
© 2019
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
ahima.org
© 2020 AHIMA
© 2019
Health Information in Judicial Proceedings
Health records are usually admissible in litigation or judicial
proceedings
• Authentication affirms a health record’s legitimacy
ahima.org
© 2020 AHIMA
© 2019
Legal Health Record (LHR)
1
• 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
ahima.org
© 2020 AHIMA
© 2019
Legal Health Record (LHR)
2
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:
• Emails and text messages
• Diagnostic images and electronic fetal monitoring strips
• Digital photography and video
• Metadata
ahima.org
© 2020 AHIMA
© 2019
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
ahima.org
© 2020 AHIMA
© 2019
AHIMA Retention Guidelines
• Ensure retention schedules are designed so patient information is
available to meet patient care needs, legal requirements,
research, education, and other legitimate uses
• 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
ahima.org
© 2020 AHIMA
© 2019
Record Destruction
1
Must take into account
• Applicable federal and state statutes and regulations
• Accreditation standards
• Pending or ongoing litigation, investigations, or audits
• Storage capabilities
• Cost
ahima.org
© 2020 AHIMA
© 2019
Record Destruction
2
Destruction may be performed by the healthcare organization that
owns the health 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
ahima.org
© 2020 AHIMA
© 2019
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
ahima.org
© 2020 AHIMA
© 2019
Medical Staff Credentialing
Healthcare organization 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
ahima.org
© 2020 AHIMA
© 2019
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
ahima.org
© 2020 AHIMA
© 2019
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