Legal Aspects Of Health Information Management

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Chapter 9

Legal Aspects of Health
Information Management
Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Legal and Regulatory Terms
• Sources of law
– Administrative law
– Case law or common law
– Statutory law

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Case Law Principles
•
•
•
•
•

Res gestae
Res ipsa loquitur
Res judicata
Respondeat superior
Stare decisis

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Subpoena Types
• Subpoena ad testificandum
• Subpoena duces tecum

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Maintaining the Patient Record in the Normal Course of Business
• The patient record is a legal business record.
• HIM professionals have the responsibility to secure and manage the patient information in the normal course of business.

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Confidentiality of Information and HIPAA Privacy and Security
Provisions
•
•
•
•

Privileged communication
Confidentiality
Privacy rule
Security rule

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Disclosure Tracking
• The tracking of disclosures must occur and can be completed using a manual or automated system. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Legislation That Impacts Health
Information Management
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Conditions of Participation (CoP)
Conditions of Coverage (CoC)
Drug and Abuse Act of 1972
Emergency Medical Treatment and Labor Act
(EMTALA)
• Federal Patient Self Determination Act
• Freedom of Information Act of 1966
Copyright © 2011 Delmar, Cengage
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