Medical Records and the Law

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ContentsPrefaceAcknowledgmentsAbout the AuthorsxiiixvxviiChapter 1 Introduction to the American Legal System 1Chapter Objectives 1Introduction 1The Nature of Law 2Sources of Law 3The Constitution 3Statutes 6Decisions and Rules of Administrative Agencies 8Court Decisions 9Governmental Organization and Function 11Organization of the Court System 13State Court System 14Federal Court System 15Chapter 2 Medical Records and Managed Care 19Chapter Objectives 19Introduction 19Utilization Review 20Managed Care 20Managed Care Organizations and Related Entities 21Health Maintenance Organizations 21Preferred Provider Organizations 22Independent Practice Associations 23Group Practice Without Walls 23Consolidated Medical Group 23Physician/Hospital Organizations 24Management Services Organizations 24Foundation Model Integrated Delivery System 24iii
ivCONTENTSPhysician Ownership Model Integrated DeliverySystem 25Other Managed Care Organizations 25The Impact of Managed Care on Health InformationManagement 26HIPAA and State Privacy Rules 28Changes in Medical Records Standards 30Chapter 3 Medical Records Requirements 31Chapter Objectives 31Records That Must Be Kept 31The Legal Health Record 33Content Requirements 35Record Retention Requirements 40Statutory and Regulatory Concerns 41Statutes of Limitations 43Medical Research and Storage SpaceConsiderations 44Association and Accreditation AgencyGuidelines 46Developing a Record Retention Policy 47Destruction of the Record 48Chapter 4 Medical Records Entries 51Chapter Objectives 51Introduction 52Legible and Complete Medical Records Entries 53Timely Medical Records Entries 58Authorship and Countersignatures 59Authentication of Records 62Auto-Authentication 66Verbal Orders 68Corrections and Alterations 69Chapter 5 Document Consent to Treatment 73Chapter Objectives 73Introduction 74Legal Theories of Consent 76Express and Implied Consent 76Informed Consent 78
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Page 11 and 12: xCONTENTSTheories of Liability 400D
Page 13 and 14: xiiCONTENTSState HIPAA Statutes 531
Page 15 and 16: xivPREFACEand accessible text and a
Page 18 and 19: About the AuthorsWilliam H. Roach,
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32 CHAPTER 3: MEDICAL RECORDS REQUI
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52 CHAPTER 4: MEDICAL RECORDS ENTRI
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74 CHAPTER 5: DOCUMENT CONSENT TO T
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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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Special Documentation Concerns 271T
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Special Documentation Concerns 273w
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Celebrity PatientsSpecial Documenta
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Special Documentation Concerns 277t
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BackgroundSpecial Documentation Con
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Special Documentation Concerns 281g
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Special Documentation Concerns 283m
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Special Documentation Concerns 285m
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Special Documentation Concerns 287A
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Special Documentation Concerns 289r
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Special Documentation Concerns 291p
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Special Disclosure Concerns 293mark
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Special Disclosure Concerns 295clos
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Special Disclosure Concerns 297•
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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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Special Disclosure Concerns 309exam
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State Law ProvisionsSpecial Disclos
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Special Disclosure Concerns 313Heal
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Special Disclosure Concerns 315the
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Special Disclosure Concerns 321give
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Special Disclosure Concerns 325crea
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Special Disclosure Concerns 329the
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Special Disclosure Concerns 331ance
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Special Disclosure Concerns 333to c
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Special Disclosure Concerns 335In g
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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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Medical Records and the Law

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