Medical Records and the Law

Index 579of alcohol and drug abuse, 187–194amendments to PHIs, 231–235de-identified information, 106–109designated record sets, 111documentation of designations, 153duplication fees, 196–199duplication rights, 227duty to consult prior medicalrecords, 491by employers, 182–183of ePHIs, 454facility directories, 172by family and friends, 170–171, 231genetic information, 194–196HIPAA administrativerequirements, 242–245HIPAA confidentialityrequirements, 115–120HIPAA covered entities, 141–145HIPAA notices, 218–227hybrid entities, 149–151international privacy standards,139–140limited data sets, 109–110mental health records, 183–187minimum necessary rule, 146–149minors, 173OHCAs, 153–156by or on behalf of patient, 157–164ownership, 111–114preempting HIPAA, 135–139Privacy Rule. see Privacy Rule,confidentiality lawsprofessional judgment in, 145to protected health information,105–106QIO record keeping, 199–205requests for accounting of PHIdisclosures, 235–238requests to receive confidentialcommunications, 230restricting uses of PHIs, 227–230revocation of patient authorizations,168–170for treatment, payment or healthcareoperations, 177–182utilization review and qualityassurance, 205–208verifying identity, 239–241violations, reporting, 238–239medical records access, businessassociates, 208–218liability, 217–218non-HIPAA requirements for,214–216qualifications, 208–213written agreements for, 213–214medical records access, federal law,114–129Constitution, 115Freedom of Information Act(FOIA), 123–127HIPAA, 115–120Medicare Conditions ofParticipation, 127–128others, 128–129Privacy Act of 1974, 120–122substance abuse, 128USA Patriot Act, 122–123medical records access, state lawHIPAA preemption of, 135–139medical records statutes andregulations, 130–133open records laws, 133–135overview of, 129–130patient authorizations, 166–169medical records entries, 51–72authentication, 62–66authorship vs. countersignatures of,59–61auto-authentication systems, 66–68correcting and altering, 69–72legibility and completeness of,53–58overview of, 52–53timeliness of, 58–59verbal orders affecting quality of,68–69