Legal and Ethical Considerations in Health Records Questions And Answers.
Legal uses for the health record - Answers -To establish the applicable standard of
care, as evidence in civil actions, as evidence involving the credentialing process, for
disciplinary proceedings of healthcare professionals, to establish the cause of death, to
determine BAL, to support an insanity defense, as proof of a party's physical condition.
Subpoena - Answers -A command issued by a court or other authorized official to
appear and/or present certain documents and other things.
Show cause order - Answers -An order to explain why the person should not be held in
contempt for failing to obey a previous court order.
Motion to quash - Answers -An approved method to challenge the validity of a
subpoena duces tecum, requesting a court to examine the subpoena to determine
whether the health information professional must produce the documents or can legally
withhold some or all of the documents sought.
Intentional tort - Answers -A tort committed by one who intends to do the act that
creates the harm.
Nonintentional torts - Answers -Torts committed by persons who lack the intent to do
something wrong.
HIPAA Patient Rights - Answers -Rights include access to protected health information,
notification of privacy practices, limiting use or disclosure of information, requesting
confidential communication, accounting of disclosures, and filing complaints regarding
privacy practices.
Authorship - Answers -Identifies the health-care provider who has made an entry in the
patient record, in writing or by dictation, keyboard, or keyless data entry.
Authentication - Answers -Confirms the content and accuracy of an entry into the
medical record by written signature, initials, or computer-generated signature code.
Individual Identifiers under HIPAA - Answers -Includes name, all address information,
dates (birth, death, admission, discharge), telephone numbers, fax numbers, e-mail
addresses, social security number, health record number, health plan beneficiary
number, account numbers, certificate/license numbers, vehicle identifiers, device
identifiers and serial numbers, URLs, IP addresses, biometric identifiers, facial
photographs, and any other unique identifying number, characteristic, or code.
Advanced Directive (AD) - Answers -A legal document in which an individual gives
written instructions expressing his or her wishes regarding health care in the event that
person can no longer make those decisions.
Living will - Answers -A document that indicates what medical intervention an individual
wants if he or she becomes incapable of expressing those wishes.
, Legal and Ethical Considerations in Health Records Questions And Answers.
Durable Power of Attorney (POA) - Answers -A document that permits an individual to
appoint another person to make any decisions regarding health care if the principal
should become unable to make decisions.
HIPAA (Health Insurance Portability and Accountability Act) - Answers -The Privacy
Rule sets a standard where the health care provider may seek the patient's consent
before using protected health information to carry out treatment, payment, and health
care operations.
ARRA - Answers -The American Recovery and Reinvestment Act of 2009 modifies the
health care provider's ability to honor or not honor a patient's request to restrict
disclosure of PHI.
ROI - Core Elements - Answers -Includes individual's name and identifying information,
a specific and meaningful description of the information to be disclosed, identification of
the person authorized to make the requested use or disclosure, identification of the
person to whom the disclosure is made, an expiration date or event, a statement of the
individual's right to revoke the authorization, and a statement that the information may
lose its protected status upon redisclosure.
Redisclosure Statement - Answers -A statement that the information that is used or
disclosed is subject to redisclose and may lose its protected status.
Signature and Date - Answers -The signature and date of the individual.
Representative Authority - Answers -If the authorization is signed by the individual's
representative, a description of the representative authority.
Minimum Necessary Standard - Answers -Principle that individually identifiable health
information should be disclosed only to the extent needed to support the purpose of the
disclosure.
GINA - Answers -Act that prohibits discrimination on the basis of someone's genetic
information or the genetic information of his or her family.
HIV/Substance Abuse/Psychiatric - Answers -These are all protected under HIPAA and
need additional consent to release information.
Risk Management - Answers -A nonclinical function that focuses on how to reduce
medical, financial, and legal risk to an organization.
Fraud and Abuse - Answers -Defined as a false misrepresentation of fact that is relied
on by another to that person's detriment and is a departure from reasonable use.
Legal uses for the health record - Answers -To establish the applicable standard of
care, as evidence in civil actions, as evidence involving the credentialing process, for
disciplinary proceedings of healthcare professionals, to establish the cause of death, to
determine BAL, to support an insanity defense, as proof of a party's physical condition.
Subpoena - Answers -A command issued by a court or other authorized official to
appear and/or present certain documents and other things.
Show cause order - Answers -An order to explain why the person should not be held in
contempt for failing to obey a previous court order.
Motion to quash - Answers -An approved method to challenge the validity of a
subpoena duces tecum, requesting a court to examine the subpoena to determine
whether the health information professional must produce the documents or can legally
withhold some or all of the documents sought.
Intentional tort - Answers -A tort committed by one who intends to do the act that
creates the harm.
Nonintentional torts - Answers -Torts committed by persons who lack the intent to do
something wrong.
HIPAA Patient Rights - Answers -Rights include access to protected health information,
notification of privacy practices, limiting use or disclosure of information, requesting
confidential communication, accounting of disclosures, and filing complaints regarding
privacy practices.
Authorship - Answers -Identifies the health-care provider who has made an entry in the
patient record, in writing or by dictation, keyboard, or keyless data entry.
Authentication - Answers -Confirms the content and accuracy of an entry into the
medical record by written signature, initials, or computer-generated signature code.
Individual Identifiers under HIPAA - Answers -Includes name, all address information,
dates (birth, death, admission, discharge), telephone numbers, fax numbers, e-mail
addresses, social security number, health record number, health plan beneficiary
number, account numbers, certificate/license numbers, vehicle identifiers, device
identifiers and serial numbers, URLs, IP addresses, biometric identifiers, facial
photographs, and any other unique identifying number, characteristic, or code.
Advanced Directive (AD) - Answers -A legal document in which an individual gives
written instructions expressing his or her wishes regarding health care in the event that
person can no longer make those decisions.
Living will - Answers -A document that indicates what medical intervention an individual
wants if he or she becomes incapable of expressing those wishes.
, Legal and Ethical Considerations in Health Records Questions And Answers.
Durable Power of Attorney (POA) - Answers -A document that permits an individual to
appoint another person to make any decisions regarding health care if the principal
should become unable to make decisions.
HIPAA (Health Insurance Portability and Accountability Act) - Answers -The Privacy
Rule sets a standard where the health care provider may seek the patient's consent
before using protected health information to carry out treatment, payment, and health
care operations.
ARRA - Answers -The American Recovery and Reinvestment Act of 2009 modifies the
health care provider's ability to honor or not honor a patient's request to restrict
disclosure of PHI.
ROI - Core Elements - Answers -Includes individual's name and identifying information,
a specific and meaningful description of the information to be disclosed, identification of
the person authorized to make the requested use or disclosure, identification of the
person to whom the disclosure is made, an expiration date or event, a statement of the
individual's right to revoke the authorization, and a statement that the information may
lose its protected status upon redisclosure.
Redisclosure Statement - Answers -A statement that the information that is used or
disclosed is subject to redisclose and may lose its protected status.
Signature and Date - Answers -The signature and date of the individual.
Representative Authority - Answers -If the authorization is signed by the individual's
representative, a description of the representative authority.
Minimum Necessary Standard - Answers -Principle that individually identifiable health
information should be disclosed only to the extent needed to support the purpose of the
disclosure.
GINA - Answers -Act that prohibits discrimination on the basis of someone's genetic
information or the genetic information of his or her family.
HIV/Substance Abuse/Psychiatric - Answers -These are all protected under HIPAA and
need additional consent to release information.
Risk Management - Answers -A nonclinical function that focuses on how to reduce
medical, financial, and legal risk to an organization.
Fraud and Abuse - Answers -Defined as a false misrepresentation of fact that is relied
on by another to that person's detriment and is a departure from reasonable use.
