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Subpoena
command issued by the court
Court order
used to get a release of medical information protected under HIPAA
subpoena duces tecum
requests production of records and documents
subpoena ad testificandum
command a witness to appear and give testimony
Dual function of medical records:
provides information for patients' care
evidence in malpractice suits
Hippocratic Oath
traditional vow of the physician pertaining to the ethical practice of medicine, duty, and confidentiality.
Doctor-Patient Privilege
A relationship in which a patient's medical history, conditions, and related information can't be made known without that patient's permission
informed consent
communication between a doctor and a patient in which the doctor explains the factors involved in a recommended medical process.
Substituted consent
involves an authorized person making a medical decision for a person who is unable to do so.
Covered Entity
organizations that handle protected health information in any capacity. They include:
- Healthcare providers
- Healthcare clearing houses
- Health plans
limited data set
contains information of a patient record with a restricted number of identifiers such as geographic location and dates.
Privacy rule of HIPAA
provides special rules regarding psychotherapy notes that limit use or disclosure without consent. It requires that patients be given a notice of use or disclosure of patient-specific information.
Attorney-Client Privilege
protects medical incident reports distributed to the facility's attorney
National Practitioner Data Bank (NPDB)
must be informed by an entity making malpractice payment
Quality Management
traditionally performed by peer review committees.
Biometrics
aids in associating a patient with his/her correct medical records.
demostrative evidence
something that helps illustrate a witness's testimony, such as a map, chart, photograph, x-ray, videotape, movie, sound recording, or model
Competent Evidence
evidence that the court should accept into proof
Hearsay
Evidence in which witnesses aren't telling what they know personally, but rather what others have said to them
Medical records
a document that includes a patient's history, condition, diagnostic and therapeutic treatment, and the results of treatment
Author of a Medical Record
the medical provider who has created the data that appear in the record
Authentication
the confirmation of the content of an entry in a medical record; must be performed by the person who creates the data
Age of Majority
When a person becomes an adult
certificate of destruction
Documents that records were properly destroyed in the ordinary course of business
Freedom of Information Act (FOIA)
A federal law intended to provide access to government records
Privacy Act of 1964
prohibits disclosure of certain medical information by government agencies unless the patient gives written consent
Legal Basis for Confidentiality
The right of privacy derived from the Constitution, statutes, and the common law
Three Groups to which HIPAA Regulations Apply
health care providers, health plans, health care clearinghouses
Protected Health Information (PHI)
Any individually identifiable health information
Identifiable Information
Data about a specific person
de-identified information
Information stripped of data that may identify an individual
Treatment
the provision of healthcare and related services
Payment
The activities of healthcare providers to obtain payment or be reimbursed for their services and the activities of a health plan to obtain premiums, to fulfill their coverage responsibilities and provide benefits under the plan, and to obtain or provide reimbursement for the provision of healthcare
Health care operations
Certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment
Occupational Safety and Health Administration (OSHA)
Responsible for enforcing safety rules in the workplace
Whistleblower
An employee who informs OSHA of illegal activity
mutual consent registry
One method many states use to arrange the consents required for the release of identifying information related to adoptions
Substance abuse
refers to the excessive use (or abuse) of alcohol or drugs
Genetic Information Nondiscrimination Act (GINA)
Adopted in 2008; designed to prevent the discriminatory use of genetic information by employers and insurers
Centers for Disease Control and Prevention (CDC)
Serves as a national focus for developing and applying disease prevention and control., environmental health, and health promotion and education activities designed to improve the health of the people of the U.S.
Enzyme Immunoassay (EIA)
The most common screening test used to look for HIV antibodies
Consumer-Controlled Test Kits
Popularly known as home testing kits; first licensed in 1997; used to collect a blood sample to send to a licensed laboratory for testing
Ways to Transmit HIV/AIDS Virus
Transmitted in four common ways: High-risk sexual contact Injection drug use Transmission from mother to child around the time of birth Blood transfusions and other unknown causes
Routine HIV Testing
The CDC has recommended routine HIV testing for all Americans between 13 and 64 as a regular part of their healthcare
Risk Management
identifies areas of risks to medical service providers
Loss Prevention
A planned, systematic, and proactive process; in the area of healthcare, providers such as hospitals identify those activities, problems, and situations that may result in potential liability for the hospital, its employees, physicians, and even other healthcare providers
Loss reduction
The steps taken after an event or incident occurs
Incident report
Proper documentation of adverse incidents that occur during the treatment of a patient
Peer review committees
Consist of health professionals who monitor the quality and use of healthcare services
Use of biometrics
1. To identify a patient
2. To simplify secure access to records
Medical records custodian
Should know the hardware, software, and procedures for data entry to lay a foundation to admit medical records
Ways to reduce security breaches of medical records
a. use good passwords
b. change them frequently and don't share them
c. use biometrics instead of password
d. reduce unnecessary access to medical records by creating different levels of access based on the need to know
e. train employees in safe practices, such as logging off immediately after access
f. install appropriate software to guard against hacking, spyware, viruses, and the like
h. implement appropriate protections, such as backing up files
________ doesn't directly identify a patient, but may contain some identifiers.
a limited data set
Which of these is a special type of health information?
information related to substance abuse treatment
Which of these is a rule the Health Insurance Portability and Accountability Act includes?
protected health information includes any individually identifiable health information
Mandatory HIV testing may be ordered for whom?
individuals who present health threat to others
What is the name of the legal rules that provide protections for workers from situations at work that are known to be potentially able to cause injury or death?
Occupational Safety and Health Act
Specifying that only certain persons may pull medical files or that medical files not in use must be filed immediately is an example of what type of safeguard?
administrative
Healthcare providers who make entries in a medical record must do so when?
At the time that the event occurs.
The legality in which a patient's medical history, conditions, and related information can't be made known without that patient's permission is:
doctor-patient privilege
Attorney-client privilege and __________ are two methods to avoid incident reports being subject to discovery by a plaintiff during litigation.
work product doctrine
The AMA's Code of Medical Ethics states that the information disclosed to a physician during the course of the doctor-patient relationship is
confidential to the utmost degree.
An employer's use of medical records to decide whether or not a patient is disabled is what type of use?
nonclinical use
The process of communication between a doctor and patient in which the doctor explains the factors involved in a recommended medical process is called what?
informed consent
A __________ should document that medical records were properly destroyed in the ordinary course of business.
certificate of destruction
Most states require doctors practicing telemedicine across state lines to have what type of license?
a license in each state where the patients live or where physical care is being given
Evidence in which witnesses aren't telling what they know personally, but rather what others have said to them is what type of evidence?
Hearsay
According to the AMA, what is a key reason behind physicians' duty of confidentiality to patients?
Patients will feel more confident in disclosing information to their physicians.
__________ is one type of information that must be reported to the NPDB.
medical malpractice payment
A hospital is required to query the NPDB when
a practitioner applies for temporary privileges
Which of the following factors would be considered de-identified information?
Patient condition: improved breathing with new medication
The main purpose of a peer review committee is to:
identify activities that suggest guidelines aren't being followed
Which of the following pieces of information would be allowed as part of a limited data set?
Birth date
Which of the following activities is considered part of health care operations under HIPAA?
reviewing the competency of health care workers
What law provides access to government records, with exception for records with medical information?
Freedom of Information Act
Under what circumstances may a health insurer charge a higher premium to a woman with a genetic disposition to breast cancer?
Health insurers can never discriminate based on genetic information in this way.
Which of the following statements is true of patients' right to have errors corrected in their medical records?
The Dr. doesn't have to make the change but the patient is entitled to a written notice of the decision
Which one of the following steps can shield against discovery of an incident report?
Invoking the work product doctrine
A mutual consent registry is relevant to obtaining medical information about
a party to an adoption
Which of the following is not an example of a limited data set?
unique identifying numbers
Which of the following statements is true of HIPAA rules regarding the release of PHI by covered entities to business associates?
Covered entities must require adequate assurances in writing that business associates will adequately safeguard PHI
Suppose the statute of limitations for a particular state is three years and the age of maturity in the state is 21. If you have a medical records for a 13-year-old girl, how long should you maintain them?
11 years
If an institutional review board is involved in a request for PHI, the information is likely sought by a?
a healthcare facility
Rita works as a medical coder for an ambulatory surgery center. Under the terms of HIPPA, is Rita considered a covered entity?
Maybe, depending on her employment status.
What is a doctor's responsibility if a patient requests restrictions on the use of his/her PHI?
the doctor need not comply with the patient's wishes if HIPAA would otherwise permit the use.
Which of the following is an example of demonstrative evidence?
Map
A patient's authorization for disclosure of PHI must include the purpose of the disclosure and what information is to be released if the PHI relates to
treatment for substance abuse
Which of the following statements about risk management is true?
risk management is concerned with reducing exposure to legal liability.
The __________ is the only person who can authenticate the information in a patient's medical record.
The "person who creates the data" in the record
Which of the following statements about HIV testing is true?
Some HIV tests can provide results in as little as 20 minutes
