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Ch15 Hlth Inf Mngmt

Privacy & Health Law

legal written document specifying patient's preferences regarding future health care or specifies another person to make medical decisions in event patient had incurable/irreversible condition & is unable to communicate wishes; patient must be competent advanced directive
rather than settling dispute in court, neutral party/panel hear both sides & renders decision, or by settling claims against them by negotiating direct payment to party bringing claim in exchg for clmt dropping the claim alternative dispute resolution
laws prohibiting anti-competitive behaviors such as price discrimination, restraint of trade, and monopolies antitrust
settling of a dispute outside of court through neutral party/panel arbitration
deliberate threat, coupled with apparent ability to do physical harm to another person without that person;s consent; no contact is required assault
process of verifying/confirming identity of a user that is requesting to access the information authentication
context of patient authorizing disclosure of their protected health information; refers to written permission that meets requirements of applicable law that is required to be able to disclose the info authorization
courtroom personnel who are present to assisting keeping order, administering oaths, guarding & assisting jury, & performing other duties at direction of the judge bailiff
nonconsensual, intentional touching of another person in socially impermissible manner battery
rules of evidence require that when originals are still available, they must be produced. when it becomes necessary to prove contents of a document, original must be produced or its absence accounted for. best evidence rule
when one part to a contract fails to follow the terms agreed to in the contract breach of contract
when a plaintiff brings a civil suit against a defendant, unless plaintiff can convince judge/jury by a preponderance of evidence that claims against defendant are valid, the defendant will prevail burden of proof
special agreement required by HIPPA that covered entities must use when using outside agents/organizations to handle/process protected health info on their behalf; ensures the agency follows rules set by covered entity for handling protected health info business associate agreement
in deciding on cases when no statutes apply, judges refer to similar cases that have been decided in past & by applying same principles, courts generally arrive at same ruling in current case as in similar previous cases case law
doctrine that has, until the early=mid 1960s, protected nonprofit hospitals from liability for harm to patients; courts now permit harmed patients to sue hospitals for their wrongful acts charitable immunity
administrative manager of court who handles paperwork associated w/lawsuits; complaints are filed w/clerk, as are pleadings & documents clerk of the court
large body of principles that have evolved from prior court decisions common law
written statement by plaintiff that states claim & commences the action in a lawsuit complaint
communication that transmits info to health care provider as part of relationship between provider & patient under circumstances that imply that info shall remain private confidential communications
written permission from patient allowing care/treatment consent
documentation made while care is being provided, while the info is fresh in care provider's mind contemporaneous documentation
formal & binding agreement; actual/implied contract
under this theory, courts can hold HCOs liable for their own independent acts of negligence corporate negligence
written/verbal order issued by the court court order
individual responsible for creating verbatim transcript of court proceedings court reporter
any entity that is a health plan, health care clearinghouse, or health care provider conducting certain transactions in electronic form & must comply w/HIPPA's Privacy Rule covered entity
process of granting/renewing certain privileges to practice medicine to prospective/existing members of medical staff at a facility credentialing
oral/written communication to person (other than defamed) tending to damage the defamed's reputation in eye's of community defamation
party(s) in a lawsuit from whom relief/compensation is sought from the plaintiff defendant
refers to data that have been stripped of certain patient identifiers deindentified
sworn verbal testimony deposition
HIPPA terms used to include records that contain protected health info maintained by/for a covered entity designated record set (DRS)
process whereby each party is party a lawsuit seeks to discover important info about case through a pretrial investigation discovery
the right to a full hearing due process
a competent adult names in writing another adult to make any medical decisions on their behalf in the event they become incapacitated. durable power of attorney for health care
minors who can make their own health care decision without parental/guardian involvement emancipated minor
information legally presented at trial, offered to prove or disprove an issue under contention evidence
unlawful restraint of person's personal liberty or unlawful restraining/confining of a person; physical force not required only that there is reasonable fear that force will be used to detain/intimidate the person into following orders false imprisonment
willful & intentional misrepresentation that could cause harm/loss to a person/person's property fraud
HIPPA terms used to describe activities that may need to use/reference protected health info, when use is directly related to operation of health care entity & handled appropriately health care operations
bars legal admissibility of evidence that is not the personal knowledge of the witness hearsay rule
paper-based/electronic report completed by health care professionals when a variance occurs from usual process of patient care/when a mishap/injury occurs involving a patient, staff member, or visitor incident report
research & human rights advisory board, part of most healthcare facilities & universities meeting at least quarterly institutional review board (IRB)
claims pertaining to intentional harm intentional tort
form of testimony interrogatory
negligent disregard for patient's privacy invasion of privacy
power of a federal, state, etc. court to hear a dispute jurisdiction
written document allowing a competent adult to indicate their wishes regarding life-prolonging medical treatment should they be unable to consent living will
professional negligence malpractice
principle of HIPPA privacy rule, only minimum necessary amount of info necessary to fulfill purpose of request should be shared w/internal users & external requestors minimum necessary
motion files by legal counsel in which court is asked to set aside the subpoena/order motion to quash
conduct that society considers unreasonably dangerous; failure to provide a reasonable level of care. negligence
factual summaries of unexpected events that have/could have resulted in injury/harm to patients/staff/visitors. occurrence report
party that initiates the lawsuit plaintiff
when defendant files an answer to the complaint from the plaintiff pleading
legally recognized authority to act & make decisions on behalf of another party power of attorney
rulings of similar previous cases precedent
override pre-empt/pre-emption
when weighing whether something is true/not true when evidence supports the case by 51% preponderance of evidence
right of individuals to control disclosure of their personal info privacy
statements made to attorneys, priests, physicians, spouses, or others in a legally recognized position of trust privileged communication
HIPPA rule that any individually identifiable health information should be kept confidential protected health information
primary or substantial cause of an injury proximate cause
whistleblower-based prosecutions qui tam
if a claim involves simple, not professional, negligence the jury uses this standard to evaluate the defendant parties' conduct in light of jury's own general experience & background "reasonable man" standard
dictates of government agencies charged with enforcing & implementing legislation in a particular area; dictates are designed to carry out the intent of the law regulation
doctrine: HCOs must take reasonable steps to supervise actions of their employees/professional staff, incl. medical staff respondeat superior
contracts/agreements that tend to/are designed to eliminate/stifle competition, create a monopoly, artificially maintain prices, or otherwise hamper/obstruct course of trade/commerce restraint of trade
constitutionally recognized right to be left alone, to make decision's about one's own body, & to control one's own info right of privacy
subpoena duces tecum validity for hlth info under HIPPA: reasonable efforts by party seeking info ensuring subject of protected health info given notice of request or has secured qualified protective order that meets HIPPA privacy rule satisfactory assurance
HIPPA & good business practices require HCOs implement administrative, technical, & physical safeguards to protect confidentiality, integrity, & appropriate availability of hlth info maintained in paper/electronic format security of health information
generally accepted standards for each profession determined by referring to current standards published by relevant specialty society & professional literature standard of care
legal principle that courts should decide similar cases similarly; cases with similar facts & questions should ordinarily be decided in the same way stare decisis
law enacted by Congress or state legislatures statute
law requiring claims to be filed within certain period of time; otherwise claims will not be heard by a court statute of limitations
written court order that requires someone to come before the court to testify subpoena
written court order that requires someone to come before the court & to bring certain records/documents named in that order subpoena duces tecum
action where one party alleges another party's wrongful conduct has caused them harm; the party bringing action to court seeks compensation for that harm tort
individual who goes outside regulatory bodies in an org. to raise a problem rather that reporting a suspected unlawful activity internally whistleblower
authorized employees of an org. as used in the HIPPA privacy rule workforce
alternative dispute resolution is also referred to as mediation / arbitration
applicant's background reviewed, licenses/certifications checked, proof of current liability insurance verified & practice patterns/quality review data evaluated to determine whether privileges should be granted during the credentialing process
responsible for monitoring activities of people who function within their facility whether employees or independent contractors & for complying w/ appropriate industry standards under the corporate negligence theory
when referring to the corporate negligence theory, the appropriate industry standards refers to the Joint Commission standards, licensing regulations, & Medicare's Conditions of Participation
oral defamation of character that tends to damage the defamed's reputation in eyes of community slander
written defamation of character that tends to damage the defamed's reputation in eyes of community libel
to encourage our-of-court resolution of cases by acquainting all parties w/pertinent facts discovery phase
depositions & interrogations, during the discovery phase, are considered pertinent testimony
in addition to pertinent testimony, the discovery phase includes obtaining ___ under the control of the opposing party documents
when referring to a durable power of attorney for health care, the extent of the decision-making power varies from state to state
under the law an emancipated minor is treat as an adult & have the right to consent to treatment & authorize disclosures of their health information
if information is allowed to be used at trial it can be "admitted into evidence"
interpreted & applied by judges in deciding what info can be admitted into evidence & both federal gov. & individual states have rules of evidence
conducting quality improvement activities, contacting patients w/info about treatment alternatives, providing w/educational info, evaluating practitioner/provider performance, accrediting, licensing & credentialing are HIPPA's definition of health care operations activities
during HIPPA's health care operations activities no specific ___ is required on the part of the individual(s) whose info is being accessed authorization
incident reports are meant to be nonjudgmental, ___ ___ of the event & its consequences, if any factual accounts
incidents reports are prepared to assist in identifying & correcting problem-prone areas & in preparation for __ __ legal defense
is to protect human subjects/patients from research risks & invasion of privacy, by reviewing all research studies that involve subjects/patients, incl. experiments, interviews, questionnaires, & any study data from patient's MR the aim of an IRB
assault & battery, false imprisonment, defamation of character, invasion of privacy, fraud/misrepresentation, & intentional infliction of emotional distress are all claims falling under intentional tort
are sworn written answers to questions interrogatories
uses or disclosures for treatment purposes & where patient has specifically authorized release of more info are (2) of only a few situations where the minimum necessary standard does not apply
occurrence reports are used by HCOs __ __ or __ to investigate incidents that have potential to become claims against org./provider & identify areas where improvements are needed risk managers & attorneys
in a pleading the defendant ___ or otherwise responds to the defendant's claim denies
preponderance of evidence is considering "more likely than not"
the confidentiality of privileged communications is generally protected by law from being ___, even in court revealed
determining the proximate cause of an injury is often a difficult question involved in ______ litigation negligence/malpractice
under respondeat superior, organizations can be held liable for damages when their employees fail to perform their duties adequately
restraint of trade is when the medical/professional staff credentialing process interferes with a physician's/health professional's ability to pursue his/her profession
right of privacy is an important ___ ___ for the health care community constitutional right
HIPPA's focus for security of health info is on protected health info in __ __ electronic format
stare decisis "let the decision stand"
statute of limitations are designed to encourage timely filing of claims
timely filing of claims, under the statute of limitations, allows for the evidence to be fresh and witnesses to be available
in most states the statute of limitations begins at the time of the event
statute of limitations in a health care case begins at the __ __ __ if the patient was treated as a minor age of majority
tort takes place in private law
must be completed as soon as they are detected using the proper methods outlined in facility's policy/procedure manual error correction
in situations where simple error correction methods are insufficient addenda
when a patient asks for an amendment to their records HIPPA's privacy rule permits such requests, but only for facility's operated by the federal government
if a physician believes that an amendment request is inappropriate, reason falling under permissible reason under HIPPA privacy act for denying the change, physician must speak with patient in regards
patient's amendment requests should be handled as an addendum to record without changes to the original entry
outlines an appeal process that must be made available to patient if their request for amendment is denied, & they wish to appeal denial Section 164.526 of HIPPA privacy rule
includes "personnel & medical files & similar files, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy" (1) of (9) exempt categories under FOIA
info must be contained in personnel, medical, or similar file; disclosure of info constitutes invasion of personal privacy; severity of invasion must outweigh public's interest in disclosure; interpreting 3-part test subject of a number of court cases "unwarranted invasion of privacy" under FOIA
it is generally accepted that the facility owns the health record itself
is subject of patient's ownership interest in the info within the record exercise of ownership rights by the facility
authorizations that do not contain all required elements are considered invalid authorizations
releasing info when there is an invalid authorization, is a violations of the HIPPA privacy rule and can result in penalties
internal uses for disclosure for patient care purposes should be on a need-to-know basis
HIPPA's privacy rule permits disclosure of protected health info for treatment purposes without authorization
patient care, quality review, financial, legal, education and research are all___ uses of the PR legitimate
a HIM professional does ___ & ___ analysis of each patient record to assure it consistency and completeness. qualitative & quantitative
a HIM professional facilitates record-keeping for professionals by providing transcription services and developing the most efficient procedures for record completion
a HIM professional ___ all records and prepares them for ___. codes; billing
a HIM professional guards the ___ of records and supervises their transmittal to those authorized to see them. confidentiality
a HIM professional participates in quality assurance, utilization review and ___ activities. risk management
a HIM professional provides __ __ to various medical staff activities. record-keeping services
data for board certification of physicians, management planning, research, regulatory agencies, & special/financial reports are provided by a HIM professional
"The patient has not received all of the services he needs and deserves if his " record is not current and complete
In court, the medical record IS the care rendered. If it isn't in the record," it didn't happen