HLTH 4445 Test 3 Review: The Medical Record, Patient Confidentiality, and Workplace Law

Comprehensive vocabulary flashcards covering medical record standards, patient confidentiality, HIPAA, workplace law, employment ethics, and billing regulations for HLTH 4445 Test 3.

Timeliness

The documentation principle requiring healthcare providers to document care when provided or as soon as possible.

Completeness

The documentation principle requiring the inclusion of all relevant findings, treatment, and follow-up.

Credibility

The documentation principle requiring the recording of accurate, objective facts while avoiding speculation.

HIPAA Access Request Response Deadline

The statutory timeframe under HIPAA requiring providers to generally respond to a patient access request within 30 days.

AHIMA Adult Record Retention Recommendation

A professional recommendation—not a universal law—to retain adult medical records for about 10 years after the last encounter.

EMR (Electronic Medical Record)

A digital chart generally used within one practice.

EHR (Electronic Health Record)

A digital health record designed for sharing across multiple providers.

PHR (Personal Health Record)

A health record managed directly by the patient or family.

Subpoena duces tecum

A legal order requiring specified records or documents to be produced in court.

Privacy

The patient's legal and ethical right to control their personal information.

Confidentiality

The healthcare professional's legal and ethical duty to protect patient information.

Privacy Act of 1974

A federal law that protects personal records maintained by federal agencies, such as the Veterans Affairs (VA).

HIPAA (1996)

Federal legislation establishing national standards for health information privacy, security, and transactions, while granting patients access and amendment rights.

HITECH Act (2009)

Legislation that promotes EHR adoption, strengthens breach notification requirements, and increases HIPAA enforcement and accountability.

Covered Entities

Organizations subject to HIPAA regulations, specifically health plans, healthcare clearinghouses, and covered healthcare providers.

Business Associates

Vendors and contractors handling protected health information (PHI) on behalf of covered entities, such as billing companies.

Protected Health Information (PHI)

Individually identifiable information relating to an individual's health status, healthcare provision, or payment for healthcare.

ePHI

Protected Health Information (PHI) that is stored or transmitted electronically.

HIPAA Privacy Rule

A HIPAA Title II rule governing how PHI may be used or disclosed and defining patient rights regarding their health information.

HIPAA Security Rule

A HIPAA Title II rule mandating administrative, physical, and technical safeguards for protecting ePHI.

Transactions and Code Sets Rule

A HIPAA Title II rule that establishes standard electronic healthcare transactions and medical data code sets.

Unique Identifiers Rule

A HIPAA Title II rule establishing standard national identifiers for covered healthcare transactions.

HIPAA Enforcement Rule

A HIPAA Title II rule establishing procedures for compliance investigations, hearings, and penalties for violations.

Notice of Privacy Practices (NPP)

A written notice that covered entities are required to give patients explaining how their PHI may be used and disclosed.

Treatment, Payment, and Healthcare Operations (TPO)

Categories of health information sharing that are generally permitted under HIPAA without obtaining written patient authorization.

Incidental Disclosure

A secondary disclosure of PHI that cannot reasonably be prevented and is permitted under HIPAA when reasonable safeguards are used.

Minimum Necessary Standard

The requirement to share only the PHI reasonably needed to accomplish a purpose, which generally does not apply to disclosures to healthcare providers for treatment.

Administrative Safeguards

Security Rule measures that include security policies, staff training, and formal risk assessments.

Physical Safeguards

Security Rule measures protecting electronic systems and equipment, including restricted server rooms and secured workstations.

Technical Safeguards

Security Rule technology controls protecting data access, including passwords, encryption, and automatic logouts.

HHS Office for Civil Rights (OCR)

The federal agency that investigates civil HIPAA violations and enforces regulatory compliance.

Department of Justice (DOJ)

The federal department responsible for prosecuting criminal HIPAA violations, including knowing unlawful disclosures.

Title VI – Civil Rights Act (1964)

Federal law prohibiting discrimination based on race, color, or national origin in federally assisted programs, thereby supporting language access.

ACA Section 1557 (2010)

A provision of the Affordable Care Act that prohibits discrimination on specified protected grounds in covered health programs.

Treatment Refusal

The legal principle that competent adults may generally refuse medical treatment, though courts may intervene to protect minors.

At-Will Employment

An employment arrangement where employment may generally be terminated without a stated reason, provided the termination is not for an unlawful reason or retaliation.

Just Cause

A valid, supportable, and documented reason required for employee discipline or termination under certain contracts or policies.

Wrongful Discharge

Termination of an employee that violates a specific statute, public policy, or enforceable contractual agreement.

Employee Handbook

An employer document whose written promises or stated disciplinary and termination procedures may create legally enforceable obligations.

Title VII – Civil Rights Act (1964)

Federal law prohibiting employment discrimination on the basis of race, color, religion, sex, and national origin.

Equal Employment Opportunity Act (1972)

Federal legislation that expanded the enforcement authority of the EEOC under Title VII.

Pregnancy Discrimination Act (1978)

An amendment to Title VII prohibiting employment discrimination based on pregnancy, childbirth, or related medical conditions.

Civil Rights Act (1991)

Legislation that expanded legal remedies, including monetary damages, for plaintiffs in certain employment discrimination cases.

Age Discrimination in Employment Act (ADEA, 1967)

Federal statute protecting employees and job applicants aged 40 or older from age-based discrimination.

Rehabilitation Act (1973)

Federal law prohibiting disability-based discrimination in federally funded programs and certain federal employment settings.

Americans with Disabilities Act (ADA, 1990)

Federal civil rights law prohibiting disability discrimination and requiring reasonable accommodations for qualified employees unless causing undue hardship.

ADA Amendments Act (ADAAA, 2008)

Federal legislation that broadened the statutory definition of disability under the Americans with Disabilities Act.

Quid Pro Quo Harassment

A form of sexual harassment where employment benefits are tied to unwanted sexual advances, such as a promotion offered in exchange for sexual favors.

Hostile Work Environment

A type of harassment where severe or pervasive unwelcome conduct creates an intimidating, hostile, or abusive workplace.

EEOC (Equal Employment Opportunity Commission)

The federal agency that receives and investigates employment discrimination charges, which typically must be filed within 180 or 300 days.

NLRA – National Labor Relations Act (1935)

Federal statute protecting covered workers' rights to organize, engage in collective bargaining, and act together regarding working conditions.

NLRB – National Labor Relations Board

The independent federal agency that enforces the NLRA and investigates unfair labor practice charges.

Occupational Safety and Health Act (1970)

Federal statute requiring employers to provide a workplace free from recognized hazards, enforced by OSHA.

Bloodborne Pathogens Standard (1991)

OSHA standard designed to protect workers from occupational exposure to blood and infectious materials through PPE, sharps safety, and training.

Hazard Communication Standard

OSHA standard requiring hazardous chemical labeling, Safety Data Sheets (SDS), and employee safety training.

Drug-Free Workplace Act (1988)

Federal statute requiring covered federal contractors and grant recipients to maintain drug-free workplace policies.

CLIA (Clinical Laboratory Improvement Amendments, 1988)

Federal standards established to ensure the accuracy, reliability, and timeliness of clinical laboratory patient testing.

Fair Labor Standards Act (FLSA, 1938)

Federal labor law establishing federal minimum wage and overtime pay of generally $1.5\times$ regular rates after 40 hours for covered nonexempt workers.

Equal Pay Act (1963)

Federal law requiring equal wages for men and women performing substantially equal work, subject to lawful statutory exceptions.

Social Security Act (1935)

Federal social insurance legislation providing retirement, disability, and survivor benefits.

Federal Insurance Contributions Act (FICA)

Federal law imposing employee and employer payroll taxes to fund Social Security and Medicare.

ERISA (Employee Retirement Income Security Act, 1974)

Federal statute setting minimum regulatory standards for covered employer-sponsored pension, retirement, and health benefit plans.

HMO Act (1973)

Federal law that stimulated and encouraged the development of health maintenance organizations offering network-based health plans.

COBRA (1985)

Federal law providing qualified individuals temporary continuation of employer-sponsored group health coverage after qualifying life events, typically paid by the employee.

Unemployment Compensation

A program providing temporary monetary support to eligible workers who have lost their jobs through no fault of their own.

Workers' Compensation

A state-mandated insurance program providing medical benefits and replacement wages to employees injured or made ill on the job.

Family and Medical Leave Act (FMLA)

Federal statute providing up to 12 weeks of unpaid, job-protected leave per year to eligible employees for specified family and medical reasons.

Fair Credit Reporting Act (FCRA)

Consumer protection law regulating the accuracy and fair use of credit records and entitling consumers to dispute inaccuracies.

Equal Credit Opportunity Act (ECOA)

Federal law prohibiting lenders and creditors from discriminating against applicants based on protected personal characteristics.

Truth in Lending Act (TILA)

Federal legislation requiring clear disclosure of interest rates, annual percentage rates, finance charges, and payment terms in consumer credit.

Credit CARD Act (2009)

Consumer finance reform law establishing fair practices regarding credit card interest rate hikes, fees, and billing disclosures.

Fair Debt Collection Practices Act (FDCPA)

Federal statute prohibiting abusive tactics, deceptive practices, and harassment by third-party debt collection agencies.

Federal Wage Garnishment Law

Federal law that limits the total percentage or amount of an individual's disposable earnings that can be garnished to pay debts.

Bankruptcy

A federal legal process providing debt relief to individuals or businesses, which generally halts collection actions via an automatic stay upon filing.

Claims Against Estates

The formal legal mechanism allowing creditors to recover unpaid medical bills from the assets of a deceased patient's estate.

Statute of Limitations

The legally prescribed time limit within which a creditor or healthcare provider must initiate a lawsuit to collect an unpaid debt, varying by state.