Chapter 3 Flashcards: Judicial Process of Health Information

Admissible

Pertinent and proper evidence. Rules of evidence determine if evidence is pertinent and proper. For example, in the context of medical records, the applicable rule of evidence is the hearsay rule.

Attorney–client privilege

The legal protection of communications between a client and their attorney, made in confidence for the purpose of obtaining legal advice.

Business record exception

An exception to the hearsay rule that permits business records to be admitted into evidence even though they are hearsay. Medical records admitted as evidence under this exception must first meet the foundation requirements of the exception.

Certification process

The process by which the health information manager verifies that the copy of the health record provided in response to a legal request is an exact duplicate of the original health record.

Court order

(1) An adjudication by a court. (2) The ruling by a court with respect to a motion or any other question before it for determination during the course of a proceeding.

Electronically stored information

A distinct category of information that includes e-mails, web pages, word-processing files, and databases stored in the memory of computers, magnetic discs (such as computer hard drives and floppy disk), optical discs (such as DVDs and CDs), and flash memory (such as thumb or flash drives).

Evidence

The means by which any matter of fact may be established or disproved. Such means may include testimony, documents, and physical objects. The law of evidence is made up of rules that determine what evidence is to be admitted or rejected in the trial of a civil action or a criminal prosecution and what weight is to be given to admitted evidence. Medical records may be used as evidence in civil or criminal court actions or in administrative agency proceedings.

Exigent circumstances

Generally a time-sensitive or emergency situation that allows a search to proceed without a warrant.

Foundation

One of the requirements of the business record exception to the hearsay rule. The preliminary evidence must show the relevance and authenticity of the material to be introduced into evidence.

Hearsay

Out-of-court statements that are offered to prove the truth of the matter asserted.

Hearsay rule

The rule that hearsay testimony is not admissible unless it falls within an exception to the hearsay rule.

Litigation response plan

A tool consisting of policies and procedures that address how to respond to legal process requests.

Motion to quash

An approved method to challenge a subpoena duces tecum in which a court determines whether documents and things must be produced pursuant to the subpoena.

No-knock warrant

A warrant that allows the police to enter without announcing their presence in advance

Physician-patient privledge

The legal doctrine that prevents forced disclosure of, or testimony about, information obtained by the health care provider during the course of treatment.

Plain view doctrine

A policy that allows police to seize contraband or evidence that is openly visible in an area where the police are authorized to be.

Priviledge

A concept protecting the statements made by persons within a specific relationship, such as attorney–client, from forced disclosure.

Probable cause

A belief based on specific facts that a crime has been or is about to be committed.

Show cause order

A court decree directing a person or organization to appear in court and explain why the court should not take a proposed action. If the person or organization fails to appear or sufficiently persuade the court to take no action, the court will take the action originally proposed.

Subpoena

A command in the form of written process requiring a witness to come to court to testify; short for subpoena ad testificandum.

Subpoena ad testificandum

Ad testificandum means “testify under penalty.” A subpoena ad testificandum is a subpoena to testify.

Subpoena duces tecum

Duces tecum means “bring with you under penalty.” A subpoena duces tecum is a written command requiring a witness to come to court to testify and at that time to produce for use as evidence the papers, documents, books, or records listed in the subpoena. It is often used in the context of health information management to command the custodian of the records to produce a particular record at trial or deposition and provide testimony to the authenticity of the record produced.

Trustworthiness requirements

One of the requirements of the business record exception to the hearsay rule. It must be established through testimony of the health information manager. To assist in establishing trustworthiness, the manager must possess knowledge of internal policies and procedures governing access to the medical record and quality control techniques, such as approved methods to make corrections to and use abbreviations in the record.

Warrant

A court’s prior permission for the police to search and seize.

Work-product privilege

The materials prepared in anticipation of litigation that may be shielded from discovery; sometimes referred to as the work-product doctrine.