Medical Records and the Law

ISBN-10: 0763734454
ISBN-13: 9780763734459
Edition: 4th 2006 (Revised)
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Description: 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  More...

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Book details

List price: $169.95
Edition: 4th
Copyright year: 2006
Publisher: Jones & Bartlett Learning, LLC
Publication date: 4/18/2006
Binding: Hardcover
Pages: 591
Size: 6.25" wide x 9.00" long x 1.38" tall
Weight: 1.914
Language: English

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. The Fourth Edition addresses the challenging area of how patient information may be used in connection with medical research involving human subjects.Features:- With the evolution in how health information is created, stored, retrieved, used, and transmitted, the need for protection has resulted in new and comprehensive regulation in the form of the Health Insurance Portability and Accountability Act and this book addresses its voluminous privacy, security, identifier, code set, and transactions regulations.- Medical Records and the Law, Fourth Edition provides the tools health care providers and government agents need, at all levels, given the increased focus on accountability for the quality of health care.- This book focuses on the reduction of errors and rapid access to electronic health records as an essential and fundamental part of successful quality improvement efforts.

Preface
Acknowledgments
About the Authors
Introduction to the American Legal System
Chapter Objectives
Introduction
The Nature of Law
Sources of Law
The Constitution
Statutes
Decisions and Rules of Administrative Agencies
Court Decisions
Governmental Organization and Function
Organization of the Court System
State Court System
Federal Court System
Medical Records and Managed Care
Chapter Objectives
Introduction
Utilization Review
Managed Care
Managed Care Organizations and Related Entities
Health Maintenance Organizations
Preferred Provider Organizations
Independent Practice Associations
Group Practice Without Walls
Consolidated Medical Group
Physician/Hospital Organizations
Management Services Organizations
Foundation Model Integrated Delivery System
Physician Ownership Model Integrated Delivery System
Other Managed Care Organizations
The Impact of Managed Care on Health Information Management
HIPAA and State Privacy Rules
Changes in Medical Records Standards
Medical Records Requirements
Chapter Objectives
Records That Must Be Kept
The Legal Health Record
Content Requirements
Record Retention Requirements
Statutory and Regulatory Concerns
Statutes of Limitations
Medical Research and Storage Space Considerations
Association and Accreditation Agency Guidelines
Developing a Record Retention Policy
Destruction of the Record
Medical Records Entries
Chapter Objectives
Introduction
Legible and Complete Medical Records Entries
Timely Medical Records Entries
Authorship and Countersignatures
Authentication of Records
Auto-Authentication
Verbal Orders
Corrections and Alterations
Document Consent to Treatment
Chapter Objectives
Introduction
Legal Theories of Consent
Express and Implied Consent
Informed Consent
Exceptions to the Informed Consent Requirement
Distinguishing Informed Consent and HIPAA Authorization
Who Can Give Consent
Competent Adults
Incompetent Adults
Minors
Responsibility for Obtaining Consent
Documentation
Types of Consent Forms
Short Consent Forms
Long Consent Forms
Challenges to Consent Forms
Withdrawal of Consent
Impact of State Statutes
Impact of the Medicare Conditions of Participation
HIPAA Preemption
Access to Health Information
Chapter Objectives
Introduction
Types of Health Information
Protected Health Information
De-Identification of Health Information
Limited Data Set
Designated Record Set
Ownership of the Medical Record
Summary of Confidentiality Requirements
Federal Law
State Law
International Privacy Standards
Accreditation Organizations
HIPAA Covered Entities
Healthcare Providers
Healthcare Clearinghouses
Health Plans
Exercise of Professional Judgment
Minimum Necessary Rule
Hybrid Entities, Affiliated Covered Entities, and Organized Healthcare Arrangements
Hybrid Entities
Affiliated Covered Entities
Documentation of Designations
Organized Healthcare Arrangement
Uses and Disclosures of Medical Records Information
Access by or on Behalf of the Patient
Access, Uses, and Disclosures with the Patient's Authorization
Access by Family and Friends
Facility Directories
Records of Minors
Access for Treatment, Payment, or Healthcare Operations
Access by Employers
Mental Health Records
Alcohol and Drug Abuse Patient Records
Genetic Information
Record Duplication and Fees
QIO Record Keeping
QIO Access to Individual Patient Records
Third Party Access to Information Collected by a QIO
Patient Access to QIO Information
Utilization Review and Quality Assurance
Business Associates
Qualifying as a Business Associate
Requirements for Business Associate Agreements
Non-HIPAA Required Provisions for Business Associate Agreements
Liability for Acts or Omissions of Business Associates
Additional Patient Rights Under HIPAA
Right to Notice of How a Covered Entity Will Use and Disclose PHI
Right to Have Access to, Inspect, and Copy PHI
Right to Request Restrictions on the Uses and Disclosures of PHI for Treatment, Payment, and Healthcare Operations
Right to Request to Receive Confidential Communications
Right to Request Restrictions on the Uses and Disclosures for Which an Authorization Is Not Required
Right to Request an Amendment to PHI
Right to Receive an Accounting of Disclosures of PHI
Right to Report Violations of the Regulations to the Secretary of DHHS
Verifying Identity and Representations
HIPAA Administrative Requirements
Policies and Procedures
Documentation
Personnel
Training
Sanctions Imposed on Workforce
Duty to Mitigate
Safeguards
Reporting and Disclosure Requirements
Chapter Objectives
Introduction
Disclosures Required by Law
Child Abuse and Neglect
Abuse of Adults and Injuries to Disabled Persons
Controlled Drug Prescriptions and Abuse
Occupational Diseases
Abortion
Birth Defects and Other Conditions in Children
Cancer and Other Registries
Death or Injury from Use of a Medical Device
Communicable Diseases
Misadministration of Radioactive Materials
Death
Gunshot and Knife Wounds
Other Health Related Reporting Requirements
Required Disclosure by Managed Care Organizations
Health Oversight
Documentation and Disclosure: Special Areas of Concern
Chapter Objectives
Introduction
Special Documentation Concerns
Emergency Department Records
Celebrity Patients
Hostile Patients
Recording Indicators of Child or Elder Abuse or Domestic Violence
Patients Reusing Treatment and/or Near Death
Deceased Patients and Autopsy Authorizations
Recording Disagreements Among Professional Staff
Special Disclosure Concerns
Use and Disclosures for Marketing Purposes
Use and Disclosures for Fund-Raising
Records Sought by Managed Care Organizations
Records Sought by Parties to Adoption
Records Indicating Child or Elder Abuse
Health Information Sought by Law Enforcement Agencies
Warrants and Searches
Responding to Subpoenas and Court Orders
Fraud and Abuse Investigations
Oversight for HIPAA Compliance
Use of Outside Test Reports in Hospital Patients' Records
Licensure and Accreditation
Antitrust Issues
Change of Ownership or Closure: Disposition of Records
HIV/AIDS: Mandatory Reporting and Confidentiality
Chapter Objectives
Introduction
Duty to Report
Protecting Confidentiality of HIV-Related Information
The Privacy Rule and the Security Rule
State Law
Statutory Provisions Regarding Disclosure
Disclosures Permitted by the Privacy Rule
Disclosure to Third Parties with Patient Authorization
Disclosure to Healthcare Workers
Disclosure Without Consent to Emergency Medical Personnel
Disclosure Without Consent to Spouse or Needle-Sharing Partner
Other Permissible Disclosures Without Patient Authorization
Disclosure of Healthcare Provider's Status to Patients
Disclosure by Court Order
Liability for Unauthorized Disclosure of HIV-Related Information
Recommended Policies and Procedures
Discovery and Admissibility of Medical Records
Chapter Objectives
Introduction
Discoverability of Medical Records
Physician-Patient Privilege
Admissibility of Medical Records
Medical Records as Hearsay
Other Healthcare Documentation
Peer Review Records
Incident Reports
Legal Theories in Improper Disclosure Cases
Chapter Objectives
Introduction
HIPAA Liability
Violations
Other Statutory Bases for Liability
Theories of Liability
Defamation
Invasion of Privacy
Breach of Confidentiality
Risk Management and Quality Management
Chapter Objectives
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
Chapter Objectives
The Movement to Electronic Health Records
Electronic Health Records Systems
HIPAA Privacy Rule
Privacy Rule Issues for Interoperable Electronic Health Records
Other Privacy Issues
HIPAA Security Rule
General Security Requirements
Administrative Safeguards
Physical Security Standards
Technical Security Standards
Organizational Security Safeguards
Security Requirements in Health Data Networks
State Data Security Laws
Electronic Health Records Contracting Issues
Considerations for Contracting
Health Data Network Agreements
Vendor Agreements
Participation Agreements
Regulatory Issues
Antikickback Laws
Stark Law
Tax Laws Affecting Tax-Exempt Organizations
Antitrust
Electronic Health Records as Evidence
The Rule Against Hearsay
Best Evidence Rule
The Difficulties of E-Discovery
Professional Liability
Specific Electronic Health Records Security Issues
Facsimile Transmission of Health Information
Electronic Claims Processing: The Transactions Code Set Rule
Telemedical Records
Electronic Mail
Transmission of Health Information Through the Internet
Health Information in Medical Research
Chapter Objectives
Introduction
U.S. Federal Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
The Common Rule
HIPAA Privacy Rule
Information Protected Under the Family Educational Rights and Privacy Act
Transitional Rule
Use of De-Identified Information and Limited Data Sets
Other Accommodations for Research in the HIPAA Privacy Rule
Certificates of Confidentiality
State Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
State HIPAA Statutes
State Common Law
International Laws Relating to Medical Records and Clinical Trials
European Union (EU)
United Kingdom
Canada
Japan
Other Guidance
International Conference on Harmonisation
Conclusion
Glossary: Acronyms and Definitions
Index

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