Privacy & Health Law
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| 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
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| 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
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| laws prohibiting anti-competitive behaviors such as price discrimination, restraint of trade, and monopolies | antitrust
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| settling of a dispute outside of court through neutral party/panel | arbitration
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| deliberate threat, coupled with apparent ability to do physical harm to another person without that person;s consent; no contact is required | assault
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| process of verifying/confirming identity of a user that is requesting to access the information | authentication
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| 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
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| courtroom personnel who are present to assisting keeping order, administering oaths, guarding & assisting jury, & performing other duties at direction of the judge | bailiff
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| nonconsensual, intentional touching of another person in socially impermissible manner | battery
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| 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
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| when one part to a contract fails to follow the terms agreed to in the contract | breach of contract
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| 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
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| 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
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| 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
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| 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
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| administrative manager of court who handles paperwork associated w/lawsuits; complaints are filed w/clerk, as are pleadings & documents | clerk of the court
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| large body of principles that have evolved from prior court decisions | common law
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| written statement by plaintiff that states claim & commences the action in a lawsuit | complaint
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| 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
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| written permission from patient allowing care/treatment | consent
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| documentation made while care is being provided, while the info is fresh in care provider's mind | contemporaneous documentation
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| formal & binding agreement; actual/implied | contract
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| under this theory, courts can hold HCOs liable for their own independent acts of negligence | corporate negligence
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| written/verbal order issued by the court | court order
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| individual responsible for creating verbatim transcript of court proceedings | court reporter
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| 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
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| process of granting/renewing certain privileges to practice medicine to prospective/existing members of medical staff at a facility | credentialing
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| oral/written communication to person (other than defamed) tending to damage the defamed's reputation in eye's of community | defamation
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| party(s) in a lawsuit from whom relief/compensation is sought from the plaintiff | defendant
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| refers to data that have been stripped of certain patient identifiers | deindentified
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| sworn verbal testimony | deposition
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| HIPPA terms used to include records that contain protected health info maintained by/for a covered entity | designated record set (DRS)
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| process whereby each party is party a lawsuit seeks to discover important info about case through a pretrial investigation | discovery
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| the right to a full hearing | due process
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| 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
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| minors who can make their own health care decision without parental/guardian involvement | emancipated minor
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| information legally presented at trial, offered to prove or disprove an issue under contention | evidence
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| 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
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| willful & intentional misrepresentation that could cause harm/loss to a person/person's property | fraud
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| 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
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| bars legal admissibility of evidence that is not the personal knowledge of the witness | hearsay rule
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| 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
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| research & human rights advisory board, part of most healthcare facilities & universities meeting at least quarterly | institutional review board (IRB)
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| claims pertaining to intentional harm | intentional tort
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| form of testimony | interrogatory
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| negligent disregard for patient's privacy | invasion of privacy
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| power of a federal, state, etc. court to hear a dispute | jurisdiction
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| written document allowing a competent adult to indicate their wishes regarding life-prolonging medical treatment should they be unable to consent | living will
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| professional negligence | malpractice
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| 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
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| motion files by legal counsel in which court is asked to set aside the subpoena/order | motion to quash
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| conduct that society considers unreasonably dangerous; failure to provide a reasonable level of care. | negligence
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| factual summaries of unexpected events that have/could have resulted in injury/harm to patients/staff/visitors. | occurrence report
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| party that initiates the lawsuit | plaintiff
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| when defendant files an answer to the complaint from the plaintiff | pleading
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| legally recognized authority to act & make decisions on behalf of another party | power of attorney
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| rulings of similar previous cases | precedent
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| override | pre-empt/pre-emption
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| when weighing whether something is true/not true when evidence supports the case by 51% | preponderance of evidence
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| right of individuals to control disclosure of their personal info | privacy
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| statements made to attorneys, priests, physicians, spouses, or others in a legally recognized position of trust | privileged communication
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| HIPPA rule that any individually identifiable health information should be kept confidential | protected health information
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| primary or substantial cause of an injury | proximate cause
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| whistleblower-based prosecutions | qui tam
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| 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
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| 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
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| doctrine: HCOs must take reasonable steps to supervise actions of their employees/professional staff, incl. medical staff | respondeat superior
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| 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
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| 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
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| 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
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| 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
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| generally accepted standards for each profession determined by referring to current standards published by relevant specialty society & professional literature | standard of care
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| legal principle that courts should decide similar cases similarly; cases with similar facts & questions should ordinarily be decided in the same way | stare decisis
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| law enacted by Congress or state legislatures | statute
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| law requiring claims to be filed within certain period of time; otherwise claims will not be heard by a court | statute of limitations
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| written court order that requires someone to come before the court to testify | subpoena
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| written court order that requires someone to come before the court & to bring certain records/documents named in that order | subpoena duces tecum
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| 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
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| individual who goes outside regulatory bodies in an org. to raise a problem rather that reporting a suspected unlawful activity internally | whistleblower
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| authorized employees of an org. as used in the HIPPA privacy rule | workforce
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| alternative dispute resolution is also referred to as | mediation / arbitration
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| 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
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| 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
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| when referring to the corporate negligence theory, the appropriate industry standards refers to | the Joint Commission standards, licensing regulations, & Medicare's Conditions of Participation
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| oral defamation of character that tends to damage the defamed's reputation in eyes of community | slander
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| written defamation of character that tends to damage the defamed's reputation in eyes of community | libel
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| to encourage our-of-court resolution of cases by acquainting all parties w/pertinent facts | discovery phase
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| depositions & interrogations, during the discovery phase, are considered | pertinent testimony
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| in addition to pertinent testimony, the discovery phase includes obtaining ___ under the control of the opposing party | documents
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| when referring to a durable power of attorney for health care, the extent of the decision-making power varies from | state to state
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| under the law an emancipated minor is treat as an adult & have the right to consent to treatment & authorize | disclosures of their health information
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| if information is allowed to be used at trial it can be | "admitted into evidence"
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| interpreted & applied by judges in deciding what info can be admitted into evidence & both federal gov. & individual states have | rules of evidence
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| 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
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| during HIPPA's health care operations activities no specific ___ is required on the part of the individual(s) whose info is being accessed | authorization
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| incident reports are meant to be nonjudgmental, ___ ___ of the event & its consequences, if any | factual accounts
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| incidents reports are prepared to assist in identifying & correcting problem-prone areas & in preparation for __ __ | legal defense
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| 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
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| assault & battery, false imprisonment, defamation of character, invasion of privacy, fraud/misrepresentation, & intentional infliction of emotional distress are all | claims falling under intentional tort
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| are sworn written answers to questions | interrogatories
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| 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
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| 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
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| in a pleading the defendant ___ or otherwise responds to the defendant's claim | denies
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| preponderance of evidence is considering | "more likely than not"
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| the confidentiality of privileged communications is generally protected by law from being ___, even in court | revealed
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| determining the proximate cause of an injury is often a difficult question involved in ______ litigation | negligence/malpractice
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| under respondeat superior, organizations can be held liable for damages when their employees | fail to perform their duties adequately
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| 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
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| right of privacy is an important ___ ___ for the health care community | constitutional right
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| HIPPA's focus for security of health info is on protected health info in __ __ | electronic format
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| stare decisis | "let the decision stand"
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| statute of limitations are designed to encourage | timely filing of claims
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| timely filing of claims, under the statute of limitations, allows for the evidence to be fresh and | witnesses to be available
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| in most states the statute of limitations begins at | the time of the event
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| statute of limitations in a health care case begins at the __ __ __ if the patient was treated as a minor | age of majority
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| tort takes place in | private law
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| must be completed as soon as they are detected using the proper methods outlined in facility's policy/procedure manual | error correction
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| in situations where simple error correction methods are insufficient | addenda
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| 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
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| 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
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| patient's amendment requests should be handled as an addendum to record without | changes to the original entry
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| 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
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| 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
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| 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
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| it is generally accepted that the facility owns | the health record itself
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| is subject of patient's ownership interest in the info within the record | exercise of ownership rights by the facility
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| authorizations that do not contain all required elements are considered | invalid authorizations
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| releasing info when there is an invalid authorization, is a violations of the HIPPA privacy rule and | can result in penalties
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| internal uses for disclosure for patient care purposes should be on a | need-to-know basis
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| HIPPA's privacy rule permits disclosure of protected health info for treatment purposes | without authorization
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| patient care, quality review, financial, legal, education and research are all___ uses of the PR | legitimate
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| a HIM professional does ___ & ___ analysis of each patient record to assure it consistency and completeness. | qualitative & quantitative
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| a HIM professional facilitates record-keeping for professionals by providing transcription services and developing the most efficient | procedures for record completion
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| a HIM professional ___ all records and prepares them for ___. | codes; billing
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| a HIM professional guards the ___ of records and supervises their transmittal to those authorized to see them. | confidentiality
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| a HIM professional participates in quality assurance, utilization review and ___ activities. | risk management
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| a HIM professional provides __ __ to various medical staff activities. | record-keeping services
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| data for board certification of physicians, management planning, research, regulatory agencies, & special/financial reports are provided by | a HIM professional
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| "The patient has not received all of the services he needs and deserves if his " | record is not current and complete
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| In court, the medical record IS the care rendered. If it isn't in the record," | it didn't happen
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