Medical Records and the Law

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PrefaceThe nature and use of health information has changed dramaticallysince the first edition of this book was published in 1985. Patient informationthat once traveled at the pace of paper in U.S. mail nowmoves at light speed. With the evolution in how we create, store, retrieve,use, transmit, and protect health information has come new andcomprehensive regulation in the form of the Health Insurance Portabilityand Accountability Act and its voluminous privacy, security,identifier, and code set, and transactions regulations. Patients haveemerged in this new regulatory scheme with expanded rights to controltheir health information. Healthcare providers and governments atall levels have an increased focus on accountability for the quality ofhealth care and the reduction of errors, and rapid access to electronichealth records has become an essential and fundamental part of successfulquality improvement efforts. The ability to create for every patienta community health record in electronic form, maintained in ahealth data network—and easily accessible to patients, their healthcareproviders, ancillary support providers, and other authorized individuals—isnow viewed as providing greater protection for patients, data forimportant medical and public health research, and enhanced cost savingsfor all. As the creation of health information in electronic form becomesthe norm, health information professionals must increasinglycollaborate with information technology professionals to provide secureenvironments for health information storage and safe methodologiesfor data transmission.The pace of change will continue to increaseas the healthcare industry endeavors to keep up with technological advances.The law, ever conservative, will attempt to accommodate thesechanges, without restricting innovation and creativity, while balancingthe interests of patients in maintaining confidentiality of information,the interests of providers in furthering medical science and treatment,and the interests of governments in making cost-effective health careavailable to their citizens.This fourth edition of Medical Records and the Law is once againwritten primarily for students in HIM programs as a comprehensivexiii
xivPREFACEand accessible text and as a reliable reference source for those professionalsin the health information field as well as our colleagues in thelegal profession. It addresses the substantial changes brought about byHIPAA and the growth of electronic health records systems and electronicdata networks, while retaining and updating the discussion ofstate laws affecting the use and disclosure of health information. Thebook also discusses the highly complex interplay of federal and statehealth information privacy laws. In addition to the considerable newmaterial concerning HIPAA and its regulations, this edition addressesthe challenging area of how patient information may be used in connectionwith medical research involving human subjects.Health information professionals and their attorneys will face newchallenges both in interpreting the laws governing health informationand in using the law to find creative and practical solutions to problemsthat will inevitably arise. We hope you find Medical Records and the Lawa useful tool in building the right solutions.
Page 2: Fourth EditionMedicalRecordsand the
Page 5 and 6: ivCONTENTSPhysician Ownership Model
Page 7 and 8: viCONTENTSHybrid Entities, Affiliat
Page 9 and 10: viiiCONTENTSChapter 8Chapter 9Docum
Page 11 and 12: xCONTENTSTheories of Liability 400D
Page 13: xiiCONTENTSState HIPAA Statutes 531
Page 18 and 19: About the AuthorsWilliam H. Roach,
Page 20: About the Authorsxixaged care compa
Page 23 and 24: 2 CHAPTER 1: INTRODUCTION TO THE AM
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Page 41 and 42: 20 CHAPTER 2: MEDICAL RECORDS AND M
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44 CHAPTER 3: MEDICAL RECORDS REQUI
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52 CHAPTER 4: MEDICAL RECORDS ENTRI
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100 CHAPTER 5: DOCUMENT CONSENT TO
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CHAPTER 6Access to Health Informati
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Types of Health Information 105Heal
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Types of Health Information 107The
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Types of Health Information 109•
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Designated Record SetOwnership of t
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Ownership of the Medical Record 113
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Summary of Confidentiality Requirem
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122 CHAPTER 6: ACCESS TO HEALTH INF
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CHAPTER 7Reporting and DisclosureRe
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Disclosures Required by Law 249The
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Disclosures Required by Law 251port
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Abuse of Adults and Injuries to Dis
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Disclosures Required by Law 255tity
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Disclosures Required by Law 257(suc
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Disclosures Required by Law 259The
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Disclosures Required by Law 261be c
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Other Health Related Reporting Requ
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Other Health Related Reporting Requ
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CHAPTER 8Documentation and Disclosu
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Special Documentation Concerns 269r
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Celebrity PatientsSpecial Documenta
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BackgroundSpecial Documentation Con
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Special Documentation Concerns 287A
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Special Disclosure Concerns 293mark
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Special Disclosure Concerns 299thor
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Special Disclosure Concerns 301stan
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“Good Cause” to Obtain Adoption
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Special Disclosure Concerns 305plac
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Special Disclosure Concerns 307fede
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State Law ProvisionsSpecial Disclos
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Special Disclosure Concerns 333to c
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Special Disclosure Concerns 337conf
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Special Disclosure Concerns 339AHIM
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Special Disclosure Concerns 341or r
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344 CHAPTER 9: HIV/AIDS: MANDATORY
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CHAPTER 10Discovery and Admissibili
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Discoverability of Medical Records
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Admissibility of Medical Records 38
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Admissibility of Medical Records 38
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Other Healthcare Documentation 387G
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Other Healthcare Documentation 389
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Other Healthcare Documentation 391t
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Admissibility of Incident ReportsBe
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396 CHAPTER 11: LEGAL THEORIES IN I
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CHAPTER 12Risk Management and Quali
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Relationship Between Risk Managemen
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Risk Management 425and occurrence s
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Quality Management 427• Reviewing
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Quality Management 429In its variou
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HIPAA and Risk Management/Quality M
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Compliance Programs 4333. In addres
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Compliance Programs 435• False Cl
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Medical Records in Risk Management
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440 CHAPTER 13: ELECTRONIC HEALTH R
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CHAPTER 14Health Information inMedi
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U.S. Federal Laws Relating to Acqui
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State Laws Relating to Acquisition
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International Laws Relating to Medi
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Other Guidance 539Other GuidanceIn
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Other Guidance 541rights of researc
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544 APPENDIX A: ACRONYMS AND DEFINI
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IndexAabortiondisclosure requiremen
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Index 563nature of law, 2-3overview
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Index 565clinical trials. see medic
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Index 567disclosures by victims, 32
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Index 569Do Not Resuscitate (DNR) o
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Index 571medical records destructio
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Index 573patient access to records,
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Index 575identity, 239-241, 486Illi
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Index 577organization of court syst
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Index 579of alcohol and drug abuse,
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Index 581Mississippi lawduplication
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Index 583Park Lane Medical Center v
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Index 585restricting uses of PHIs,
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Index 587quality management vs., 42
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Index 589supreme courts, state cour
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255-256HIPAA requirements, 243-245w
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