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HIT Legal Aspects

QuestionAnswer
Chapter 3 Work-product privilege The materials prepared in anticipation of litigation that may be shielded from discovery, sometimes referred to as the work product doctrine
Warrant A courts prior permission for fthe police to search and seize
Trustworthiness requirements One of the requirements of the business exception to the hearsay rule;It must be established through the testimony of the HIM (health infomation manager).To assist in establishing trustworthiness the manager must posess knowledgeof internal policies and p
Subpoena duces tecum 'duces tecum'- means "bring with you under penalty." A subpoena duces tecum is a written command requireing 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 dubpoe
Subpoena ad testificandum 'ad testificandum' means "testify under penalty" A subpoena ad testifcandum is a subpoena to testify.
Subpoena A command in the form of written process requiring a witness to come to court to testify, 'subpoena ad testificandum'
Show cause order A court decree directing a person or organization to appear in court and explain why the court should not tkae 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 ac
Probable cause A belief based on specific facts that a crime has been or is about to be committed.
Privilege A concept protecting the statements made by persons within a specific relationship, such as attorney-client, from forced disclosure.
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
Physician- patient privilege The legal doctrine that prevents forced disclosure of, or testimony about, information obtained by the health-care provider during the course of treatment.
No-knock warrant A warrant that allows the police to enter without announcing their presence in advance.
Motion to quash An approved method to challenge subpoena duces tecum in which a court determines whether documents and things must be produced pursuant to the subpoena.
Litigation response plan A tool consisting of policies and procedures that address how to respond to legal process requests.
Hearsay rule The rule that hearsay testimony is not admissible unless it falls within an exception to the hearsay rule
Hearsay Out of court statements that are offered to prove the truth of the matter asserted
Foundation Foundation requirements of the business record exception must be established during testimony by the health information manager. the manager must possess knowledge of the requirements of the requirements to create and maintain a medical record issued by
Exigent circumstances Generally a time sensitive or emergency situation that allows a search to proceed without a warrant
Evidence The means by which a matter can be established. or disproved. Can include testimony, documents, and physical objects.
Electronically stored information data that is created, altered, communicated and stored in digital form.
E-discovery the process of discovery in civil litigation that is carried out in electronic formats. It encompasses what most often is referred to as electronically stored information, or ESI.
Court order 1}an adjucication 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 proeceeding.
Certification process The process by which the health informtiion manager verifies that the copy of the health record provided in response to legal request is an exact duplicate of the original health record.
Business record exception AKA Rule 803 is an exception to the hearsay rule that permits business records to be admitted into evidence even through they are heaersay. Medical records admitted as evidence under this exception must first meet the foundation requirements of the except
Attorney-client privilege The legal protection of communictions between a client and his or her attorney, made in confidence for the purpose of obtaining legal advice.
Admissible Pertinent and proper evidence. Rules of evidence determine if evidence is pertinent and proper.
Chapter 4 Actual Damages Those damages awarded to make the plaintiff whole and restore him or her to the position in existence before the injury; sometimes referred to as compensatory damages.
Assault An act of force or threat of force intended to inflict harm upon a person or to put the person in fear that such harm is imminent; an attempt to commit a battery. The perpetrator must have or appear to have the present ability to carry out the act.
Assumption of risk A doctrine stating that a plaintiff who voluntarily exposes himself or herself to a known and appreciated danger may not recover damages caused by incurring that risk.
Battery The unconsented to touching or striking of one person by another or by an object put in motion by him or her, with the intention of doing harm or giving offense. Battery is both a cirme and a tort.
Breach of Confidentiality The unauthorized, unprivileged disclosure to a third party of nonpublic medical information that a physician or hospital has learned within a physician-patient or hospital-patient relationship.
Breach of Contract The failure to perform according to the terms of the parties' agreement.
Breach of duty of care The failure to conform to a particular standard of care toward another. Such failure to conform will result in liability for harm sustained by another person.
Causation A causing, the producing of a result.
Charitable immunity A defense that shields a charitable institution from liability for any torts committed on its property or by its employees.
Comparative negligence The doctrine adopted by most states that requires a comparison of the negligence of the defendant with the negligence of the plaintiff; the greater the negligence of the defendant, the lesser the level of care required of the plaintiff to permit him or he
Compensatory damages Those damages awarded to make the plaintiff whole and restore him or her to the position in existence before the injury; sometimes referred to as actual damages
Contributory negligence In the law of negligence, a failure by the plaintiff to exercise reasonable care that, in part at least, is the cause of an injury. Contributory negligence defeats a plaintiff's cause of action for negligence in states that have not adopted the doctrine o
Corporate negligence A doctrine defined as the failure of a hospital, entrusted with the task of providing the accommodations necessary to carry out its purpose, to follow the established standard of conduct to which it should conform.
Damages The sum of money that may be recovered in the courts as financial reparation for an injury or wrong suffered as a result of breach of contract or tort. Divided into three types; nominal, actual, punitive.
Defamation Libel or slander; the written or oral publication, false or intentional, of anything, that is injurious to the good name or reputation of another person.
Encryption A form of technical security used to ensure that data transferred from one network location to another is secure from eavesdropping or interception.
Exemplary damages Those damages awarded above and beyond actual damages, often in instances where there is proof of outrageous, malicious, or intentional conduct; sometimes referred to as punitive damages.
Duty of care An obligation, enforced by law, to conform to a particular standard of care toward another. Failure to conform to this standard will result in liability for any harm sustained by another person.
Failure to warn A negligence theory that applies to a psychotherapist's failure to take steps to protect an innocent third party from a dangerous patient. AKA as failure to protect.
False arrest The intentional detention or restraint of someone against his or her will with the intent to make an arrest or actually make the arrest.
False impisonment The illegal confinement of one individual against his or her will by another individual in such a manner as to violate the confined individual's right to be free from restraint of movement.
Good Samaritan statutes A doctrine that precludes a plaintiff from asserting a meritorious lawsuit against a governmental entity unless the governmental entity consents to the lawsuit
Governmental immunity A doctrine that precludes a plaintiff from asserting a meritorious lawsuit against a governmental entity unless the governmental entity consents to the lawsuit.
Health care relationships A; connection between a health care provider, patient, and /or hospital that serves as the basis of a lawsuit.
Hospital-patient relationship Begins when the patient is voluntarily admitted to the hospital and agrees to pay for the treatment to be rendered. The relationship ends when the patient leaves the hospital through discharge or against medical advice.
Improper disclosure The disclosure of test results or other health information to a third party without the consent of the individual treated.
Intentiontional infliction of emotional distress Conduct by the defendant that is so extreme and outrageous tha that it causes the plaintiff to suffer sever emotional distress.
Intentional torts Torts committed by persons with the intent to do something wrong.
Invasion of privacy The dissemination of information about another person's private, personal matters.
Libel Defamation expressed in print, writing, pictures, or signs and made available to a third party.
Malpractice Misconduct involving a professional who fails to follow a standard of care prevalent for his or her profession that results in harm to another person.
Medical abandonment The unilateral severing, by the physician of the physician-patient relationship without providing the patient with reasonable notice at a time when there is a necessity for continuing care.
Medical malpractice The failure of a medical professional to follow a standard of care prevalent for his or her profession that results in harm to the patient. Legal theories supporting a medical malpractice lawsuit include negligence, res ipsa loquitur ,failure to warn, vic
Medical staff privileges The scope and limit of a physician's practice in a medical institution as defined by the institution ;as defined by the institution;s governing board.
Negligence The failure to do something that a reasonable person would do in the same circumstances, or the doing of something a reasonable person would not do. Negligence is a wrong, generally characterized by carelessness, inattentiveness, and neglectfulness rather
Nominal damages Those damages awarded for the vindication of a right in which minimal injury can be proved or in recognition of a technical invasion of a person's rights.
Nonintentional torts Torts committed by persons who lack the intent to do something wrong.
Physician-patient relationship Traditionally the cornerstone of U.S. health care. Begin when the patient requests treatment and the physician agrees to render the treatment. Exists as an express or implied contract.
Protected health information (PHI) Individually identifiable health information that is transmitted by electronic media, maintained in electronic medium, or transmitted or maintained in any other form or medium.
Punitive damages Those damages awarded above and beyond actual damages, often in instances where there is proof of outrageous, malicious or intentional conduct; sometimes referred to as exemplary damages.
Res ipsa loquitur Means "the thing speaks for itself." Used only when a plaintiff cannot prove negligence with the direct evidence available to him or her.
Slander Defamation expressed by oral expressions or transitory gestures made to a third party.
Statute of limitation Federal and state laws prescribing the maximum period of time during which various types of civil actions and criminal prosecutions can be brought after the occurrence of the injury or offense.
Tort A wrong involving a breach of duty and resulting in an injury to the person or property of another.
Vicarious liability A doctrine that makes a health care organization responsible for the negligent acts its employees committed within the course and scope of their employment. AKA respondeat superior.
Chapter 1 Alternative dispute resolution A practice involving several methods of resolving conflicts and disagreements to the satisfaction of all parties without using the court system.
Appeal The process by which a higher court is requested by a party to a lawsuit to review the decision of a lower court. Review can result in; affirmation, reversal or modification of the lower courts decision.
Arbitration The use of a mutual third party to hear both sides of a dispute and render a written decision called an award.The award is imposed on the parties following consideration of each sides position.
Certiorari A writ issued by a higher court to a lower court requiring the certification of the record in a particular case so the higher court can review the record and correct any actions taken in the case tht are not in accordance with the law.
Complaint 1)The initial pleading in a civil action in which the plaintiff alleges a cause of action and asks that the wrong done to him or her be remedied by the court.2). A formal charge of a crime.
Counterclaim A claim in a lawsuit brought by the defendant against the plaintiff.
Court structures A multi tiered structure consisting of trial courts, intermediate courts of appeal and supreme courts. The structure is the same at both the state and s.federal level
Defendant The person against whom an action is brought.
Deponent The person answering the questions in a deposition.
Depositions A discovery device in which one party subpoenas a witness to appear at a given time and place to testify under oath to uncover details of a case.
Discovery A means for providing a party, in advance of trial, with access to facts that are within the knowledge of the other side to enable the party to better try his/her case. I.E. depositions, written interrogatories, The person against whom an action is brough
Diversity jurisdiction This jurisdiction of a federal court arising from diversity of citizenship when the jurisdictional amount has been met.
E-discovery Discovery that focuses on information stored electronically, such as that contained in EHI. Requires collecting, preparing, receiving & producing documents in legal proceedings.
Electronically stored information jA category of information ; incl. web pages, emails, files, databases stored in computer memory & magnetic discs( i.e. hard drives & floppy disk) thumb drives; DVD & CD, also.
Federal question jurisdiction Refers to cases that question or involve a U.S. constitutional principal, treaty, federal statute or federal rule or regulation. Also includes cases that would normally proceed in state court but not because they occurred on federal land.
Interrogatories A discovery device consisting of one party submitting written questions about a lawsuit to another party or witness.
Jurisdiction 1)In a general sense, the right of a court to adjudicate lawsuits of a certain kind 2) In a specific sense, the right of a court to determine a particular case , in other words the power of the court over the subject mattere of or property involved in the
Jury instructions Directions given to the jury by the judge before he or she sends the jurors out to deliberate and return a verdict, explaining the law that applies in the case and spelling out what must be proven and by whom.
Legal process Stages through which a lawsuit passes
Litigation hold The actions of a party who possesses electronically stored information (ESI) to make efforts to prevent routine destruction and preserve ESI that may be discoverable, even before the the when a lawsuit is filed.
Mediation The use of a neutral third party to assist both sides of a dispute in resolving their differences and reducing their resolution to writing. The resolution is based on the parties' agreement.
Mental examination A discovery device used to evaluate the mental condition of a plaintiff in a lawsuit when such condition is in question.
Metadata Unseen information in common text files, which can indicate when a document was created or revised and can contain edits, notes or other private data.
Negotiation and settlement The parties to a dispute work without the help of a neutral third party to resolution of a dispute and memorialize the resolution.
Notice of preservation A letter notifying an adversary of the need to preserve relevant electronic evidence even if paper copies are available.
Order of garnishment A written order directed to a third person to whom the losing party in a lawsuit is indebted that orders payment of the debt directly to the winning party.
Order of preservation A court order requiring a party to preserve electronic and other evidence, regardless of the party's need to engage in routine deletion or destruction practices.
Plaintiff A person who brings a lawsuit.
Personal jurisdiction The authority of a court over the parties to a lawsuit.
Pretrial conference A stage in a lawsuit prior to trial in which the status and issues of the case are discussed between the parties and the judge on a formal basis.
Production of documents and things A discovery device that permits one side of a lawsuit to inspect and copy documents and things that are not already in that side's physical possession.
Request for admission A discovery device involving written questions submitted to another party or witness designed to obtain an admission of certain facts.
Rules The principles established by authorities that prescribe or direct certain action or forbearance from action.
Satisfying the judgment A method used by the winning party in a lawsuit to collect the amount of judgement awarded (in cases involving money or property).
Service of process A stage in a lawsuit involving the delivery of the summons and complaint.
Spoiliation The wrongful destruction or material alteration of evidence or the failure to preserve property or data for another's use as evidence when litigation is pending or reasonably foreseeable
Subject matter jurisdiction The authority of a court over the question at issue in a lawsuit.
Summons 1)In a civill case the process by which an action is commenced and the defendant is brought within the jurisdiction of the court. 2) In a criminal case involving a petty offense or infraction process issued for the purposes of compelling the defendant to
Trial A hearing or determination by a court of the issues existing between parties to an ation; an examination by a court of coompetent jurisdiction, according to the law of the land, of the facts or law at issue in either a civil case or a criminal prosecution
Verdict the final decision of a jury concerning questions of fact submitted to it by the court for determination in the trial of a case.
Writ of execution A written document that orders the sheriff or other local official to take property of the losing party of a lawsuit and sell it to satisfy the judgment.
Legislative branch The branch of government responsible for enacting law.
Executive branch The branch of government responsible for enforcing and administering law.
Judicial branch The branch of government responsible for interpreting the law through adjudication and resolution of disputes.
Conflict of laws An inconsistency between different jurisdictions over the same issue in a legal action
Law A body of rules of action or conduct prescribed by controlling authority that has binding legal force
Civil law The part of the law that does not include criminal law.
Contract law Branch of law concerned with agreements between two parties that create some type of an obligation to act (do something) or refrain from acting
Chapter 5 Autonomy Independence, self-determination, or freedom
Beneficence Kindness, mercy, and charity
Best-interest standard Process of determining what is in the best interest of another who cannot determine it herself.
Categorical imperative Fundamental principle of deontology; means a command derived from a principle that does not allow exceptions.
Comparative justice Refers to balancing the competing interests of individuals and groups against one another, with no independent standard used to make this comparison. This concept posits that because the needs or interest of some individuals or grous ar egreater than the
Confidentiality The obligation of the health care provider to maintain patient information in a manner that will not permit dissemination beyond the health care provider.
Cost-benefit analysis All possible options are considered, the utility or value of each option is determined, and the option that poses the highest total utility is chosen. Net benefits are compared against costs to reach a decision. The option that offers society the best ben
Deontology Moral rules and unchanging principles derived from reason and applied universally.
Distributive justice Refers to the fair distribution of burdens and benefits using an independent standard. This concept posits that all persons have an equal opportunity to resources and requires that those in a position of authority provide the service that is due to others
Double-effect principle The principle that recognizes that ethical choices may result in untoward outcomes. One may proceed with an ethical choice presenting a double effect if the untoward outcome is not the intended outcome but a secondary outcome and is outweighed by the inte
Ethical concepts Abstract ideas or thoughts that deal with ethics
Ethical theories The systematic statements or plans of principles used to deal with ethical dilemmas.
Ethics The formal study of moral choices that conform to standards of conduct
Etiquette The principles of how human beings relate to one another under certain circumstances
Fidelity Faithfulness, loyalty and devotion to one's obligations.
Incompetent A person who is unable or unfit to make decisions.
Justice Fairness to all people.
Law body of rules of action or conduct prescribed by a controlling authority that has a binding legal force.
Morals The principles or fundamental standards of "right" conduct that an individual internalizes
Nonmaleficence Prohibition against doing harm
Patient rights Recognition that the patient is entitled to determine for him/her self the extent to which he/she will receive or forego care and treatment.
Placebo Medically inert substances that are used as a control in testing the effectiveness of another medicated substance.
Privacy Refers to the right to be left alone or the right to control personal information.
Rights A just claim or entitlement that others must respect.
Utilitarianism Promote greates balance of good over harm for everyone.
Values Concepts that give meaning to an individual's life and serve as the framework for decision making.
Veracity Habitual truthfulness and honesty.
Chapter 6 Codes of ethics Written lists of a profession's values and standards of conduct.
Conflict of interest The clash between an individual's selfish interests and his obligation to an organization or group.
Disparagement The belittling or criticizing of the skills, knowledge, or qualifications of another professional.
Ethical challenges Situations in which no clear cut "right" answer exists, and an individual is required to make a choice between two or more equally unfavorable alternatives or between a neutral alternative and a tempting but unfavorable alternative.
Ethics committees Groups formed within an organization to establish new and evaluate existing ethics codes and corporate policies and to address ethical issues that arise in the workplace.
Impaired colleagues Colleagues who can no longer function appropriately in the workplace due to substance abuse such as alcohol or drugs.
Paternalism An outdated principle in which the healthcare professional acts in the role of a father to his children, deciding what is best for the patient's welfare without first being required to consult with the patient.
Patient rights Essentially the recognition that the patient is entitled to determine for himself the extent to which he will receive or forgo care and treatment.
Created by: DkHrse