Canadian Health Information - Law
Identity theft is described as:
another person uses your personal identifiable information to impersonate you and set up new records or accounts
prima facie
based on the first impression; accepted as correct until proved otherwise.
The example of Dr. Hicks shows that health records need to:
be consistent with institutional or agency charting policies and procedures
process for responding to requests for correction and amendment
correction and amendment process
What is the main role of the Health Record Administrator?
creates a plan for researchers to follow when reviewing the information
When contacting potential research subjects, the recent trend shows which of the following making the initial contact?
custodian
When documenting health information, the best approach is a consistent perspective.
true
How many steps are involved in the challenging policy of treatment orders?
10
In which decade did we see the emergence of government hospital insurance?
1950s and 1960s
How many factors are considered when determining if the tort of defamation has occurred?
4
How many criteria must be met before a case can be considered "negligent"?
5
Provincial legislation includes exceptions to the rule of allowing microfilm into evidence. The first exception is if the original had been destroyed within a period of how many years from the time that it was considered current?
6 years
In a recent published study (from 2007), Canadian researchers were able to recover personal health information from what percentage of second hand computer disk drives sold by legitimate vendors?
65%
For purposes of federal income tax, documents should be retained for
8 years
Injunction
A court order directing a person or persons to do or not to do something for a specific time period
Habeas Corpus
A document that requires a person to be brought to court to determine if he or she is being legally detained From the Latin term meaning "you must have the body," that is, there must be grounds for detention
Acquittal
A finding of not guilty in a criminal case
Statute
A law or act passed by a government body, such as Parliament or a provincial legislature
Act
A law passed by Parliament or a provincial legislature (also called a statute)
Litigation
A lawsuit The legal action to settle a civil dispute
Affidavit
A sworn, written declaration that a certain set of facts is true
Voir Dire
A type of mini-trial held within an actual trial to decide if certain evidence is admissible
right, opportunity, means of finding, using or retrieving recorded information
Access
Determine why the person seeking access to the information requires it
Accessing
Establish a policy and procedure for patients to have access to their own health information
Accessing
Make certain that the person seeking access to the health information is entitled to it
Accessing
Obtain the identity of everyone who wants access to health information regardless of who they are
Accessing
Which of the following is a Privacy Principle, according to PIPEDA
Accuracy Openness Accountability all of the above is the right answer
Confidentiality
An obligation to keep information secret
What are the legal consequences for breach of confidentiality or invasion of privacy?
Being sued for damages
Which of the following guarantees Canadians the right to be treated equal?
Canadian Charter of Rights and Freedoms
the relationship existing between the defendant's action and the plaintiff's loss that would not have occured "but for" the defendant's actions
Causation
What is the clinical reason for collecting health information?
Client care
When health information is used in court, which rules take precedent?
federal and/or provincial rules of court
when will fees be charged, how to calculate fees, etc.
fees
clarify whether requests for access must be in writing and in a particular form
forms of request
The Purposes of Collecting/Maintaining Health Information
Clinical Cultural and Religious Services Educational Research Risk and Quality Management Peer Review and Professional Discipline Management, Audit and Inspection Insurance and Financial Legal Proceedings Legislative
Common Law (Precedent)
Common law is based on the principle of precedent Precedent is something that has been done before The rule of precedent is passed down from English law to Canada This law is common for all people
Which of the following does common law consider to be a privileged communication?
Communications between clients/physicians and Communications between clients/solicitors
a moral obligation of a health care professional to keep a client's health information private
Confidentiality
to make known or public
Disclosure
The Charter - Canadian Charter of Rights and Freedoms
Establishes: The basic rights and freedoms of Canadians The jurisdiction of the federal government and the provincial/territorial legislatures in terms of law making authority and the type of law that each may pass
What two important assertions resulted from the Krever Royal Commission of Inquiry into the Confidentiality of Health Records in Ontario? (NOTE: you will need to select two (2) options from the list below)
Everyone should have access to their own health information. Society values confidentiality of health information, which is not to be freely disclosed.
Federal Legislation
FOIP freedom of information and protection of privacy PIPEDA Personal Information Protection and Electronic Documents Act Numerous other principles are scattered throughout dozens of enactments and court decisions
Applying the standard of care to any person or institution is the same standard of care whether it be for a specialized service or not.
False
FOIP protects personal information in the private sector, while PIPEDA protects it in the public sector.
False
Sets of records will only be governed by one legislation.
False
Standards for maintaining health information are found in only one source.
False
What are financial uses of health information?
Financial and Other Administrative Processes: •To document services for payments •To bill for services •To submit insurance claims •To adjudicate insurance claims •To determine disabilities (for example, workmen's compensation) •To manage costs •To report costs •To perform actuarial analysis
Which of the following is not a Risk Management technique?
Frequency
Cultural and Religious Services
From a legal point of view, great care must be taken not to infringe provincial human rights or privacy legislation It is essential that the collection and recording of ethnic or religious information be related to services sought by the individual
What are the legal implications of cultural and religious services?
From a legal point of view, great care must be taken not to infringe provincial human rights or privacy legislation It is essential that the collection and recording of ethnic or religious information be related to services sought by the individual
How is health information used in legal proceedings?
Health information is used for a variety of legal proceedings such as beneficiaries challenging wills, families seeking custody or guardianship, personal injury litigation, and criminal proceedings Litigation arising in the health setting includes actions for negligence, assault and battery, breach of contract, and defamation. Health information therefore forms the primary line of defence
What are the legal implications of health information used for research?
Health information is used for research projects by facilities and individual practitioners. Research may involve the cause and course of illness, the effects of treatment, or the condition of patients. Poor records jeopardize the validity of research.
What are the legislative requirements in relation to health information?
Health information needs to be maintained to be in compliance with legislative requirements that are specified in various statutes and regulations Health sector legislation may not only establish documentation requirements but may also prescribe how health information may be accessed by the individual and may establish detailed rules for collecting, using, disclosing, retaining and destroying health information
Health sector legislation applies to:
Hospitals and cancer programs a and c but not b >> private health is NOT part of it
When working at a teaching hospital, why is it important to collect and maintain health records?
If the record keeping falls below the acceptable standards, the facility may not be permitted to train students. If the record keeping falls below the acceptable standards, the facility may fail to attract new students. The hospital may lose funding if they are not permitted to train students. All of the above is the right answer
Outline of PIPEDA
If your business wants to collect, use or disclose personal information about people, you need their consent, except in a few specific and limited circumstances. You can use or disclose people's personal information only for the purpose for which they gave consent. Even with consent, you have to limit collection, use and disclosure to purposes that a reasonable person would consider appropriate under the circumstances. Individuals have a right to see the personal information that your business holds about them, and to correct any inaccuracies. There's oversight, through the Privacy Commissioner of Canada, to ensure that the law is respected, and redress if people's rights are violated.
Debbie is admitted to the hospital in a coma via ambulance following a motor vehicle accident. What kind of consent for life-sustaining treatment does Debbie give?
Implied
Which of the following is an example of a form that consent may take:
Implied, written and express
One of the reasons that microfilm is better than a paper file is:
In a paper file, pages can be removed or altered
Which of the following cases showed that the health record belongs to the hospital (or other health care provider that created it)
Lamothe v. Mokleby
Which is the last group to become involved in health information issues?
Lawyers
Defaming another person in writing is called:
Libel
Legal Proceedings
Litigation arising in the health setting includes actions for negligence, assault and battery, breach of contract, and defamation. Health information therefore forms the primary line of defence. Health records are now permitted into evidence as prima facie proof of the facts stated in them
What is the relationship between documentation and education in health care facilities?
Many health agencies function as educational facilities as well as health providers. If the record keeping in the facility falls below the standard acceptable, the facility may not be allowed to train students
a careless act that causes harm to another
Negligence
a person didn't bother to read the faxed information
Negligence Issue
a person didn't check for results of an urgent test in a specific time period
Negligence Issue
a person hasn't transcribed the faxed copy properly
Negligence Issue
a person relies on a fax that can't be made out or is missing pages
Negligence Issue
Which province does not have legislation regarding the issue of whether a patient medical record prepared by a physician is the property of the physician or the patient?
New Brunswick
Discovery rules have been adopted by:
Nova Scotia
Correct
ON consent form Videotape In doctor note all of the above
What is the relationship between health information and management?
One of the most important reasons for maintaining health information is for management purposes Audit and inspection are necessary to ensure that a particular quality of service has been achieved Audit and evaluation is not restricted to the review of care and treatment of a particular patient, but examines the pattern of care and treatment provided to many patients A further purpose in maintaining health information is to obtain and maintain a license to operate Health information is used to determine eligibility for health services, responsibility for payment, and for processing and seeking payment. Health information is also used to determine if a physician has been over-treating a patient to increase claims
A policy must be established with respect to entry codes and personal identifiers on computerized records
Operating
Develop a policy on destruction of records
Operating
Do not discuss a patient's health information in public
Operating
Establish a policy on computerized information and Smartcards
Operating
Establish a protocol for reverting back to hard copy charting when computer systems fail
Operating
Establish a protocol on the use of faxed communications
Operating
Read health information in context
Operating
The method of destroying records shall be based on a uniform policy
Operating
The record must be designed in such a way as to prevent the loss or removal of pages
Operating
Constitutional Law
Outlines the structure and powers of the federal and provincial governments The Constitution is the supreme law in Canada Rights in the Charter of Rights and Freedoms are part of constitutional law Addresses the relationship between the people and their government A Canadian denied any of the rights as outlined in the Charter can challenge any person or organization denying the rights
When leaving health information in a client's home, which important information should be kept in duplicate to avoid loss of information?
all of the above which is instruction, care plan and alerts
When did the charter pass?
Passed in 1982
Normally, the ability to consent lies with:
Patient
a natural or legal person, recognized by law as having legal rights and duties, able to make commitment(s), assume and fulfill resulting obligation(s), and able of being held accountable for its action(s)
Person
a person has been appointed to decide if a document can be destroyed
Policy Ideal
a person has decided how often documents should be destroyed
Policy Ideal
a person has decided whether the documents would be destroyed on or off site
Policy Ideal
a person has outlined the acceptable methods for destroying faxed copies
Policy Ideal
a person is authorized to destroy documents
Policy Ideal
Adjournment
Postponement of court proceedings, usually at the court's discretion
a person ensures that staff knows the way to use the fax machine
Practical Rule
a person has developed a permissible transmission policy
Practical Rule
a person has developed a policy for retaining and destroying health information
Practical Rule
a person has developed a tickler follow up system
Practical Rule
a person has ensure that the individual has been notified and/or agrees to their information being sent via fax
Practical Rule
a person has ensured that an effective transmitting procedure is in place
Practical Rule
a person has made sure that the proper equipment has been selected for their office
Practical Rule
a person has made sure that there is a process for destroying information in accordance with policies
Practical Rule
a person makes sure that there is a policy on the copying of fax documents
Practical Rule
a person will ensure that the fax machine is in a secure location
Practical Rule
a person will monitor the procedures regularly to ensure that no problems are arising
Practical Rule
Stages of a Law Suit
Pre-Litigation Deciding to Act Selecting the Appropriate Court Commencing the Proceeding Pleadings Obtaining Information Before Trial (Discovery) Disposition Without Trial Case Management and ADR Pre-Trial Motions Setting the Case Down for Trial Mode of Trial Trial Judgment The Right of Appeal
the patient's right to control access to their body and personal information
Privacy
Which of the following cases stated that the record could be used as a memory trigger, but not be entered as evidence?
R. v. Gwozdowski
the standard used in determining if a person's conduct in a particular situation is negligent
Reasonable Person
information created, received and maintained as evidence and information by an organization or person, in pursuance of legal obligations or in the transaction of business
Record
Appeal
Referring a case to a higher court The judicial process by which one party to an action resorts to a superior court to correct what he/she perceives to be an incorrect determination of the original proceedings
HIMs should work with who when identifying the strategy to be followed in the event of a breach of faxed information?
Risk Management Security personnel Privacy Officer All of the above is the right answer
Section 15 in the charter?
Section 15 - equality "Every individual is equal before and under the law and has the right to equal protection and equal benefit of the law without discrimination and, in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age, or mental or physical disability"
The best way to destroy health information is:
Shredding or burning, erasing or scrambling
the level of care, or degree of caution, expected when a reasonable person is carrying out an action
Standard of Care
Statutory Law
Statute - a law passed by a legislative body As British society changed, laws were needed to address the new situations that were arising. Parliament filled in these gaps by passing new laws. The laws that were common at the time (Common Law) were now being codified and made into statutes
The charter power?
Supersedes any inconsistent statutes Protects citizens from illegal actions/activities of government
Bench
The Judge or the Court
Health information is collected primarily from:
all of the above, Hospitals Schools and prisons
Identity fraud is when:
another person uses your existing accounts to obtain a good or service
When collecting information, much depends on the setting in which the health information is used and generated.
true
Explain PIPEDA - Personal Information Protection and Electronic Documents Act
The Personal Information Protection and Electronic Documents Act (PIPEDA) sets out ground rules for how private sector organizations may collect, use or disclose personal information in the course of commercial activities. PIPEDA also applies to federal works, undertakings and businesses in respect of employee personal information. The law gives individuals the right to access and request correction of the personal information these organizations may have collected about them. PIPEDA sets out ground rules for how private sector organizations can collect, use or disclose personal information in the course of commercial activities. It balances an individual's right to privacy with the need of organizations to collect, use or disclose personal information for legitimate business purposes.
Legislation
The act of making or enacting laws Made by a provincial or territorial legislature or by Parliament To become a law, a bill (a proposed law) that has been introduced to Parliament requires the agreement of the House of Commons, the Senate, and the governor general.
Failure to be clear about the information needed may result in communication errors, how:
The correct answer is: Records may not be given to the people looking for them, and court proceedings and negotiations could be affected.
James was taken by ambulance from work to the hospital after falling and losing consciousness. Which of the following scenarios can the hospital NOT disclose without consent?
The doctor on call notified James' boss of James' diagnosis
Courts/Judiciary
The institution in society that resolves disputes in accordance with the law. Courts are also given the responsibility to ensure that the government has acted in accordance with the Constitution.
To determine whether a person's rights have been violated, the court must consider three things
The medical resources available at the time of the person's illness The demands made on those resources, and; The urgency of the individual's medical needs.
Attorney General
The member of Cabinet who is the senior legal advisor to the government and who is ultimately accountable for prosecutions
Which of the following is a conclusion that can be drawn from the rule allowing hospital records to be admissible as evidence?
The only information, which will be admissible under this rule, is that which is recorded by someone who has a duty to make the entry.
Appellant
The party that requests an appeal in criminal court - either the defence or the Crown The main party subject to the appeal
Applicant
The party who requests relief or a remedy from a court of law or other legal body
Accused
The person charged with an offence The defendant in a criminal trial
Plaintiff
The person suing in a civil action
The law of health information was found on which law?
To a certain extent, the law of health information is found in common law decisions or judge-made law
It is essential that the collection and recording of ethnic or religious information be related to services sought by the individual.
True
Legislation may from time to time be inconsistent as between statutes and regulations
True
No matter what kind of program is set up for risk management, the program needs to be continuously monitored to make sure that it is being carried out properly.
True
True of false Under the law, everyone has the right to fair assessment, but this right does not guarantee access to specific services
True
True of false When judges do comment on health information or the records, these comments are usually not binding precedent
True
True of false When health information is used in court, the federal and/or provincial rules of court and evidence take precedent
True
Unless provincial law requires otherwise, it may be best to keep incident reports separate from the health record.
True
credibility or probative value of evidence
Weight
Cross-Examination
When a witness has been called by either party, the opposite party has a right, after direct examination, to question that witness The questions a lawyer asks a witness called by the opposing side
AN HIM professional would be violating patient privacy if he/she did not have authorization from the patient or his/her representative and were to release:
a list of newborns to the local hospital for publication in the birth announcements
process for providing access to health information such as obtaining copies and viewing the original health record
access process
evidence that is accepted in legal proceedings by the presiding judge or officer as not being excluded by any rule of evidence
admissible evidence,
For the rule allowing microfilm into evidence to take effect, which of the following criteria must apply to the original health record:
destroyed by or in the presence of the employee of a physician or other health provider of health records in his or her office . destroyed by or in the presence of a physician of the institution in the case of institutional records delivered to another person (which could include a corporation) in the ordinary course of business All of the above is the right answe
When testing for common law privilege, the evidence should show all of the following, except:
disclosing would not allow for defamation
range of processes associated with implementing records retention, destruction or transfer decisions, which are documented in disposition authorities or other instruments
disposition
HIM Professionals are actively involved with and intimately aware of the privacy of PHI in health organizations. Which of the following is NOT a key activity that HIM professionals can be involved with?
ensuring appropriate background checks of employees
A photograph of a record is one step away from the person who could testify as to his or her personal knowledge of what was recorded.
false
Alberta has extremely detailed legislative requirements for retention of hospital health information.
false
All health information is required for only one purpose.
false
Consent is required before one can fax a person's health information.
false
FOIP legislation covers access to freedom of information only.
false
If there is a lapse in the health record of information being recorded, the court will generally infer nothing from this.
false
In British Columbia, "hospitals" includes nursing stations, health centres, nursing homes and the coordinated home care program.
false
In the Halushka v. University of Saskatchewan case, Dr. Olivieri hadn't disclosed the entire research procedure to Halushka.
false
It isn't necessary to arrange for a regularly scheduled risk management review.
false
Legislation has been enacted across Canada that recognizes electronic transactions as not being equally as valid as written transactions.
false
Legislation regarding the freedom of information applies to personal information in the private sector and now exists federally, provincially, and in the territories.
false
PIPEDA specifically mentions fax transmissions.
false
Required Organizational Procedures (ROP) are defined by Accreditation Canada as "an essential practice that organizations must have in place to enhance patient/client safety and maximize risk."
false
Risk managers have moved away from the "Observable Events" and instead use the traditional incident report.
false
Some provinces have passed an electronic transactions acts pursuant to the Uniform Law Conference of Canada initiative.
false
Statutory privilege is found in the Evidence Act.
false
The CIHR replaced the NSERC.
false
The Limitation of Actions Act lays out the limitation period in every province
false
The basic ground rules that apply to hard copy information does not apply to computerized information.
false
The limitation period is the same whether an action is being brought against a doctor or a nurse
false
The only type of excuse that is acceptable for not complying with such a legislative directive is if the person was unsure what to do.
false
The reason there is uncertainty about computerized health information is due in part to the excess of judicial precedent and recent amendments to existing legislation.
false
The right of access is absolute.
false
The right to confidentiality and privacy of health information is unlimited.
false
There are only four examples of how someone can be found negligent when it comes to faxing health information.
false
Treatment orders must be written.
false
When highly sensitive information is involved, it is unreasonable to tell the patient about what can be recorded in their health record.
false
When proving a case of defamation, the onus is on the care provider to prove they didn't defame the person.
false
When recording information in a patient's record, one needs not specify if drugs are administered for research purposes or for clinical treatment.
false
In a comprehensive Risk Management program, there are at least 15 chief components.
false only 5
If a provider keeps a secret file on a patient to avoid the patient seeing impressions, conjectures and opinions upon requesting access, which of the following problems could arise?
future providers will be unable to provide the proper care
documents that constitute the health record
health record
When dealing with duty to warn, what information can be disclosed about patients?
impending risk
Which of the following is NOT a distinct result of identity theft in the context of the health record?
inaccurate billing to an insurance company/agency
process of establishing access points to facilitate retrieval of records or information or both
indexing
Which of the following is NOT found in the Personal Information Protection and Electronic Documents Act (PIPEDA)?
information concerning hospital services provided to the individual
indicate whether there will be assistance for interpreting the record
interpretation
Defamation includes:
libel and slander
Section 7 in the charter?
life, liberty, and security of person.
act of moving records from one system to another while maintaining the records' authenticity, integrity, reliability and usability
migration
Which of the following information can be released without a patient's consent?
no information, including the fact that the person was treated at the facility
The by-laws of Manitoba state that the records shall include which of the following, if they are pertinent or necessary to the diagnosis and treatment:
progress notes
3 examples of forms that are needed in a file are the consent to treatment form, the waiver of liability, and the acknowledgment by the patient that personal items are in the care of the facility. What should be done if the patient/client is unable or unwilling to sign the documents?
record of the events that would lead to the document(s) would be made by the staff
All entries must be signed
recording
Choose whether the following policies are "recording health information", "accessing health information", or "operating a health information system". Use a uniform system of recording information throughout the organization
recording
Do not add editorial comments
recording
Do not assume that those who will be reading the handwritten information are familiar with the handwriting
recording
Do not assume that you can always read your own handwriting with accuracy
recording
Encourage the use of handwritten block letters rather than cursive
recording
Read the entry immediately after making it
recording
Record concisely
recording
Record information immediately or as soon as possible
recording
The person who made the entry must sign all entries
recording
Try not to change pens in the midst of writing an entry in the record
recording
Use uniform abbreviations throughout the facility
recording
evidence that has any tendency in reason to prove a fact in issue in a proceeding
relevant evidence
process for communication to individuals of the right to request a review of decisions
reviews
The best way to destroy health information is:
shredding or burning and erasing or scrambling
record containing information or data entered into an RMS
source record
educate and support staff handling access requests
staff education
The charter grantees certain right but tempered by which phrase?
subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society
who has authority to request access on behalf of other individuals
substitue decision makers
Which of the following are major legal issues arising from medical orders (please select all answers that apply):
tandard of Care issue and Evidentiary issue
Which of the following are examples of provincial legislation
the Controlled Drugs and Substances Act Food and Drugs Act Income Tax Act none of the above is the right answer
Which criteria need to be met in order for by-laws to become valid internal legislation?
the by-laws must be adopted according to the procedure established in the articles of the incorporating documents of the corporation they must not contravene any provincial or federal act or regulation they must not deal with any subject outside the purpose for which the corporation has been established all of the above is the right answe
After reading the section titled "Ownership", what is the one outcome that is arrived at?
the health provider owns the record, but the patient has a right to access record
Which is a foolproof way to keep faxed information confidential?
there is no foolproof way to keep faxed information confidential
The relationship between a Health Information Manager professional and the risk manager includes:
they work as a team the risk manager depends on the HIM professional to alert him/her of potentially compensable events the HIM professional can advise the risk manager when a lawyer requests a copy of a health record All of the above is the right answer
establish mechanisms to manage the 30-day time frame and extensions for processing access requests
time
Donnie has refused to provide consent for access to his health information. The only time you will be able to release information without his consent is:
to Public Health if Donnie has a communicable disease
A fundamental principle of law in any civilized society is that no one may interfere with the body of another person without that person's consent.
true
A specific person should be in charge of risk management.
true
According to the 1980 Saskatchewan Hospital Standards Regulations, each physician will sign the parts of the health record that he/she is responsible for.
true
Fax transmissions are considered part of the health record if placed in the patient's chart.
true
Health care fraud is defined as an "intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other party."
true
Health information is written in clinical terminology, which is not easily understood and could be misleading to the individual.
true
If a fax forms part of the health record, the regular rules for retention and disposal will apply.
true
In Nova Scotia, the Hospitals Act governs all hospitals whether public or psychiatric.
true
Microfiliming is the most common way to store files
true
No health care facility wants to be the "test case" that is used to determine these issues
true
One of the difficulties with an electronic record is determining whether the original is the record stored in the computer or rather is the computer generated printout of that record, or whether both are originals.
true
Provincial regulations exist that allow information to be used for research without permission from the patient.
true
Specific legal requirements exist for particular industries.
true
The Narcotic Control Regulations fall under the Controlled Drugs and Substances Act.
true
The Tri-Council's statement is extremely important for researchers to follow because the Tri-Council are the major source of funding of research projects.
true
The health record is the property of the health care provider.
true
The six-year retention requirements of originals does not apply to governments.
true
The three factors that must be present to meet the criteria for duty to warn to exist are 1) a clear risk to an identifiable group of persons, 2) a serious risk of bodily harm including serious psychological harm, or 3) death and an imminent danger.
true
There are 2 types of privilege discussed in this chapter: solicitor-client and litigation.
true
Thomas is recording Sally's notes as she has directed him to do verbatim, and one of Sally's notes if defamatory. Thomas can be held responsible for the defamatory statement.
true
Without records staff are not always able to communicate with one another regarding the patient's condition and what should or should not be done for the patient.
true
he main reason for collecting and maintaining health information is to enable health personnel to provide treatment and care for the patient.
true