Exam 2 - Legal Aspects Of Health Information & Risk Management

Who needs to sign authorizations for release of records during different situations?

• Power of Attorney - authority to act for another person in specified or all legal or financial matters. POA for Healthcare = authority to act for another person in specified or all legal and health matters

• Legal guardian - court appointed to handle the matters of all the incompetent adult

• Custodial parent - parent that lives with and cares for their minor child for all or most of the time

• Emancipated minor - one who is under the age of majority and self-supporting with parents who have surrendered their rights of custody care, and support

  • Marriage, divorce, in the military

• Child parent - under the age of 18 and has a child. Individuals are responsible for personal health records as well as their child’s

  • Expect for child parent, all must carry legal documents

What happens to records when a clinic closes or facility closure?

• Required to send a public notification to indicate closure

  • Offer to transfer records to a new provider or send records to patient within a specific timeframe

  • Transfer to storage firm under a written contract to abide by HIPAA and state law.

What happens when a clinic closes and there is a ownership change?

The healthcare organization is sold or merged with another healthcare organization if a clinic closes

• Transferred to successor

  • Mostly because they want to keep “customer base”

• Physician may retire and turn caseload over to new hire

• May have to request a new physician by asking which physicians are taking new patients - usually goes to the new doctor to build up practice

What is the order to obtain consent for health care decisions by family members?

• Adult spouse

• Adult children

• Parents

• Adult siblings

• Extended family members

What records are credible for use as court evidence?

Courts rely on records that meets standards of authenticity, reliability, and accuracy.

• Original medical records

• Certified copies of medical records

• Electronic Health Records (EHR)

• Provider notes & progress notes

• Audit trails

What different ways to protect the confidentiality of celebrity patients?

• Diversion

• Disguise

• Limit access - lock units to avoid employees getting into a celebrity’s unit

• Set up a perimeter or press room

  • No cameras inside the building, able to identify other patients

• Pseudonames - fake names/alias

A malpractice claim is filed 7 years after surgery; the hospital must produce the operative report, why?

legal defense

Medicare requires certain documentation to be kept for at least 5 years for audit purposes, why?

compliance with laws & regulations

A cancer registry requests pathology reports from cases diagnosed 8 years earlier, why?

public health reporting

What are some don’ts in documentation principle charting?

1. Don’t leave gaps or holes in record information

2. Not using white-out

3. Recopying, erasing, or scribbling out info

4. Not to incriminate other staff, document personal views

5. Co-sign what has not been read

6. Incriminate yourself

What are some do’s in documentation principle charting?

1. Write legibly

2. Use acceptable abbreviations - must only have 1 meaning

3. Be concise, clear, pertinent

4. Chart factual observations and descriptions

5. Date and time every entry

Which organization recommends record retainment laws?

AHA

What is the adult patient record industry standard?

10 years after most recent encounter

What is the birth, death, surgical registries industry standard?

permanently

How long does a hospital keep the disease, operation, physician indices?

10 years

What is the minor patient record industry standard?

age of majority (18)

What is the diagnostic images record industry standard?

5 years

How long does the hospital keep your master patient index?

permanently

What is the difference between HIPAA retention and standards law?

Review the case of Behringer vs. Princeton and know what they were found liable for.

In the case, they were found liable for …

• Breach of confidentiality - failed to protect AID test results; widespread gossip

• Discrimination

What situations can be reported that occur within a substance abuse treatment center?

• Abuse counselor (vandalize, or threaten or hurt another patient)

• According to the FDA

What is reporting elder abuse and neglect?

Right of self-determination over 60+ has the confidence to pick up medications, driving, or etc

Who should go to if you have a question regarding release of information?

risk manager

When should records be released?

authorized request by the patient; complete disclosure

When should records not be released?

no authorized request; missing pieces of information like proof of identity, birthday, signatures

What paperwork must be presented with an authorization, in order to release the records?

What’s the role ASTM plays in medical record?

longitudinal electronic health record

Review auto-authentication of physician dictated reports.

Automatic signature incomplete queue; sign all

Know what the legal health record is and who it is defined by.

• Asks as the business record; trustworthy

• Release upon valid request

What can be problematic for documenting in electronic health records?

• Cut, copy, and paste

• Not cross-checking information

• Converting records from EHR and not typing them

What UPA is and what it allows?

• States that the reproduction of any record that has been retained in the regular course of business and kept by a process which accurately reproduced the original in any medium will be admissible as evidence

  • Supports the transition from paper to electronic storage of information

  • Must be reliable and be able to reproduce an exact copy of the original

  • Must survive changes in operating systems and upgrades

  • Allows record reproductions to be admitted as evidence

What’s the age of majority?

18

Which law will trump others?

strictest law

Review Empancipated minors

1.      Know what situations can be reported that occur within a substance abuse treatment center

Who you should go to if you have a question regarding release of information.

1.      Know where you need to report the following: controlled drug prescription, communicable diseases, gunshot and suspicious knife wounds, and controlled Drug Prescription abuse.

1.      Know when you will need to provide various types of paperwork including: power of attorney, executor of estate, proof of identity, custody papers, and state foster papers to receive records.

Review how long you need to keep records for based on AHA recommended minimum retention periods.

Know when records can be released and when they cannot. Know what paperwork must be presented with an authorization, in order to release the records.

Who needs to sign a consent for when a media crew interviews a patient?

Anyone who could be identified if they’re present

What is the Health Information Exchanges and what is accomplished using HIE?

exchange PHI between entities by network participation

What the Federal Area on Aging Ombudsman is and what it investigates.

What federal regulations for confidentiality of alcohol or drug abuse records apply to?

anybody identified

When does a patient quotes are used in medical record documentation?

• Hostile towards staff or others

• No other names in it

What factors influence health record retention periods?

When can you confirm patients are seeking treatment and when they you cannot?

• Facility Directory can mention the treatment or room

• Patient would have to opt in for any information to other members of the family

What are the steps to release records from a hospital?

• Receive mail/request – fax, phone, mail, in person

• Enter in log

• Validate authorization

• Validate the identity of the patient and retrieve record

• Identify information to release

• Print and verify information

• Enter in log and release

• Release by mail, in person, fax

Who governs worker’s compensation record?

State is going to govern worker’s compensation records

Who or what requires co-signing?

specified and required by medical staff bylaws; legally binding; required in some states; “Did co-signer actually read the documentation?”

What’s the appropriate way to document disagreements in a medical record?

• Cold hard facts; get to the point

• State the action of the record; without disagreeing to it

• Patient quotes

• Don’t list names