Medical Records and the Law

by Roach, William

• ISBN13: 9780834211049
• ISBN10: 0834211041
• Edition: 3rd
• Format: Hardcover
• Copyright: 1998-05-01
• Publisher: Jones & Bartlett Pub

Summary

Gardner, Carton & Douglas, Chicago, IL. A Brandon/Hill Allied Health List selection. Previous edition: c1994. Focuses on the analysis of the legal issues affecting health information management, the role of a variety of health care providers, uses of data, and the concerns that have arisen in this environment.

Table of Contents

Preface	xiii	(2)
Acknowledgments	xv
Chapter 1 Introduction to the American Legal System	1	(16)
Introduction	1	(1)
The Nature of Law	2	(1)
Sources of Law	3	(7)
The Constitution	3	(1)
Due Process of Law	4	(1)
Equal Protection of the Laws	5	(1)
Right of Privacy	5	(1)
State Constitutions	6	(1)
Statutes	6	(1)
Decisions and Rules of Administrative Agencies	7	(1)
Court Decisions	8	(2)
Governmental Organization and Function	10	(2)
Organization of the Court System	12	(5)
State Court System	12	(2)
Federal Court System	14	(1)
Stare Decisis	15	(2)
Chapter 2 Medical Records and Managed Care	17	(11)
The Impact of Managed Care on Health Information Management	17	(5)
Managed Care Organizations and Related Entities	22	(6)
Health Maintenance Organizations	22	(1)
Preferred Provider Organizations	22	(1)
Exclusive Provider Organizations	23	(1)
Independent Practice Associations	23	(1)
Group Practice Without Walls	24	(1)
Consolidated Medical Group	24	(1)
Physician/Hospital Organizations	24	(1)
Management Services Organizations	25	(1)
Foundation Model Integrated Delivery System	26	(1)
Physician Ownership Model Integrated Delivery System	26	(1)
Utilization Review Organizations	26	(2)
Chapter 3 Medical Record Requirements	28	(16)
Records that Must be Kept	29	(2)
Content Requirements	31	(5)
Record Retention Requirements	36	(6)
Statutory and Regulatory Concerns	36	(2)
Statutes of Limitations	38	(1)
Medical Research and Storage Space Considerations	39	(1)
Association Guidelines	40	(1)
Developing a Record Retention Policy	41	(1)
Destruction of the Record	42	(2)
Chapter 4 Medical Record Entries	44	(18)
Introduction	45	(1)
Legible and Complete Medical Record Entries	45	(5)
Timely Medical Record Entries	50	(1)
Authorship and Countersignatures	51	(2)
Authentication of Records	53	(5)
Auto-Authentication	56	(2)
Verbal Orders	58	(1)
Corrections and Alterations	59	(3)
Chapter 5 Documenting Consent to Treatment	62	(25)
Introduction	63	(1)
Legal Theories of Consent	64	(9)
Express and Implied Consent	65	(1)
When is Consent Implied?	65	(2)
Informed Consent	67	(1)
What Information Must be Disclosed?	68	(1)
Proving Causation	69	(1)
Medical Experimentation and Research	70	(1)
Exceptions to the Informed Consent Requirement	70	(1)
Emergencies	71	(1)
Therapeutic Privilege	71	(1)
Patient Waiver	72	(1)
Treatment of Criminal Suspects and Prisoners	72	(1)
Who Can Give Consent	73	(5)
Competent Adults	73	(1)
Refusal of Consent	74	(1)
Incompetent Adults	75	(1)
Minors	76	(1)
Emergency Care	76	(1)
Emancipated Minors	77	(1)
Mature Minors	77	(1)
Parental or Guardian Consent	78	(1)
Responsibility for Obtaining Consent	78	(3)
Documentation	81	(1)
Types of Consent Forms	82	(5)
Short Consent Forms	82	(1)
Long Consent Forms	83	(1)
Challenges to Consent Forms	84	(1)
Withdrawal of Consent	84	(1)
Impact of Statutes	85	(2)
Chapter 6 Access to Medical Record Information	87	(53)
Introduction	87	(1)
Ownership of the Medical Record	88	(3)
Confidentiality Requirements	91	(12)
State Law	91	(4)
State Open Records Laws	95	(1)
Federal Law	96	(1)
Constitution	96	(1)
Privacy Act	97	(1)
Freedom of Information Act	98	(4)
Medicare Conditions of Participation	102	(1)
Accreditation Organizations	102	(1)
Access to Medical Record Information	103	(20)
Access by or on Behalf of the Patient	103	(5)
Records of Minors	108	(2)
Access by Staff	110	(3)
Psychiatric Records	113	(3)
Alcohol and Drug Abuse Patient Records	116	(6)
Genetic Information	122	(1)
Disclosures for Medical Research	123	(4)
Record Duplication and Fees	127	(2)
Record Security	129	(1)
PRO Recordkeeping	130	(6)
PRO Access to Individual Patient Records	131	(1)
Third Party Access to Information Collected by a PRO	132	(3)
Patient Access to PRO Information	135	(1)
Utilization Review and Quality Assurance	136	(4)
Chapter 7 Reporting and Disclosure Requirements	140	(13)
Introduction	140	(11)
Child Abuse	141	(3)
Abuse of Adults and Injuries to Disabled Persons	144	(1)
Controlled Drug Prescriptions and Abuse	145	(1)
Occupational Diseases	145	(1)
Abortion	146	(1)
Birth Defects and Other Conditions in Children	146	(1)
Cancer	147	(1)
Death or Injury from Use of a Medical Device	147	(1)
Communicable Diseases	147	(1)
Misadministration of Radioactive Materials	148	(1)
Death	149	(1)
Gunshot and Knife Wounds	149	(1)
Other Health-Related Reporting Requirements	150	(1)
Required Disclosure by Managed Care Organizations	151	(2)
Chapter 8 Documentation and Disclosure: Special Areas of Concern	153	(60)
Introduction	154	(1)
Special Documentation Concerns	155	(21)
Emergency Department Records	155	(6)
Celebrity Patients	161	(2)
Hostile Patients	163	(1)
Recording Indicators of Child Abuse	163	(1)
Patients Refusing Treatment and/or Near Death	164	(1)
Background	164	(1)
Patient Self-Determination Act	165	(2)
Living Will Legislation	167	(2)
Durable Power of Attorney	169	(2)
Do-Not-Resuscitate Orders	171	(3)
Deceased Patients and Autopsy Authorizations	174	(1)
Recording Disagreements Among Professional Staff	175	(1)
Special Disclosure Concerns	176	(24)
Records Sought by Managed Care Organizations	176	(3)
Records Sought by Parties to Adoption	179	(2)
"Good Cause" to Obtain Adoption Record Information	181	(1)
Responding to Record Requests	182	(2)
Records Indicating Child Abuse	184	(3)
Records Sought by Law Enforcement Agencies	187	(2)
Warrants and Searches	189	(3)
Responding to Subpoenas and Court Orders	192	(1)
Subpoenas	193	(1)
Court Orders	194	(1)
Compliance Requirements	195	(3)
Fraud and Abuse Investigations	198	(2)
Use of Outside Test Reports in Hospital Patients' Records	200	(3)
Licensure and Accreditation	200	(2)
Antitrust Issues	202	(1)
Change of Ownership or Closure: Disposition of Records	203	(10)
Change of Ownership	204	(3)
Closure	207	(6)
Chapter 9 HIV/AIDS: Mandatory Reporting and Confidentiality	213	(27)
Introduction	214	(1)
Duty to Report	215	(3)
Protecting Confidentiality of HIV-Related Information	218	(2)
Statutory Provisions Regarding Disclosure	220	(18)
Disclosure to Third Parties with Patient Authorization	220	(1)
Disclosure to Health Care Workers	221	(4)
Disclosure without Consent to Emergency Medical Personnel	225	(2)
Disclosure without Consent to Spouse or Needle-Sharing Partner	227	(3)
Other Permissible Disclosures without Consent of Patient	230	(1)
Disclosure of Health Care Provider's Status to Patients	231	(2)
Disclosure by Court Order	233	(1)
Court Orders and Disclosure in Blood Donor Cases	234	(2)
Liability for Unauthorized Disclosure of HIV-Related Information	236	(2)
Recommended Policies and Procedures	238	(2)
Chapter 10 Discovery and Admissibility of Medical Records	240	(18)
Introduction	240	(1)
Discoverability of Medical Records	241	(6)
Physician-Patient Privilege	242	(3)
Waiver of the Physician-Patient Privilege	245	(1)
Physician-Patient Privilege vs. The Public Interest	246	(1)
Admissibility of Medical Records	247	(3)
Medical Records as Hearsay	248	(1)
Business Record Exception to the Bar on Hearsay	248	(1)
Other Exceptions to the Bar on Hearsay	249	(1)
Other Health Care Documentation	250	(8)
Peer Review Records	251	(2)
Admissibility of Peer Review Records	253	(1)
Practical Tips	254	(1)
Incident Reports	254	(2)
Admissibility of Incident Reports	256	(1)
Practical Tips	256	(2)
Chapter 11 Legal Theories in Improper Disclosure Cases	258	(20)
Introduction	258	(1)
Statutory Bases for Liability	259	(1)
Theories of Liability	260	(14)
Defamation	260	(1)
Privileges Against Defamation	261	(4)
Consent as a Defense	265	(1)
Invasion of Privacy	265	(3)
Photographs	268	(1)
Invasion of Privacy Within the Health Care Setting	269	(1)
Payment-Related Disclosures	269	(1)
Disclosure to the News Media	270	(4)
Breach of Confidentiality	274	(4)
Defenses Against Breach of Confidentiality	276	(2)
Chapter 12 Risk Management and Quality Review	278	(12)
Introduction	278	(1)
Relationship Between Risk Management and Quality Review	279	(1)
Risk Management	280	(2)
Quality Review	282	(3)
Compliance Programs	285	(3)
Medical Records in Risk Management, Quality Review, and Compliance Activities	288	(2)
Chapter 13 Computerized Medical Records	290	(38)
Emerging Trends in Computerization of Medical Records	291	(3)
Legal Issues Raised by Computerized Medical Records	294	(15)
Confidentiality and Integrity Issues	295	(3)
System Security Measures	298	(3)
Implementing System Security	301	(2)
Implementing External Security	303	(2)
Computer Sabotage	305	(1)
Preserving Access to Computerized Records	306	(1)
Durability Concerns	307	(1)
Accuracy Issues	308	(1)
Computerized Medical Records As Evidence	309	(3)
The Rule against Hearsay	309	(2)
Best Evidence Rule	311	(1)
Specific Electronic Patient Information Security Issues	312	(16)
Facsimile Transmission of Medical Records	312	(2)
Electronic Claims Processing	314	(1)
Telemedical Records	315	(1)
Electronic Mail	316	(6)
The Internet	322	(6)
Appendix A--Glossary: Acronyms and Definitions	328	(7)
Index	335