Legal and Ethical Aspects of Health Information Management- Ch 8

How can an electronic health record be corrected?

An addendum is added to the electronic health record reflecting the correction. The original document/entry in the electronic health record is not altered, but a computer code attribute is used to reference the original document to the addendum.

A Condition of Participation for Medicare is that a history and physical examination be completed and documented no more than 30 days before or 48 hours after admission or prior to anesthesia.

FALSE

Completion of the medical record including final diagnosis must be within 48 hours following discharge of the patient to meet Medicare Conditions of Participation.

FALSE

Compare and contrast the clinical uses of a health record with the secondary purposes of a health record.

Health records are used for a variety of clinical purposes, including serving as the chronological record of a patient's care, as a method of communication for current and subsequent episodes of care, and as the basis of research and quality improvement activities. As such, health records are used by clinicians. Health records serve secondary purposes that are not clinical in nature, including the billing function, the legal record of a patient's care, and the documentation to support a claim of disability. As such, health records are used by nonclinicians.

How does a health record serve as a legal document?

It serves as the way to reconstruct an episode of patient care. This reconstruction provides the ability to prove what did or did not happen in a particular case and establish whether the applicable standard of care was met.

Is it legally proper for a physician in a group practice to sign medical entries made by another physician in the same practice? Why or why not?

Ordinarily, it is not legally proper for the physician to sign medical entries made by another physician, because authentication principles dictate that only the author of the entry may authenticate the entry. The exception would be where specific accreditation standards or regulations allowed for this action.

What legal requirements apply to a record retention policy?

Statutes on the state level and regulations on the both the federal and state levels apply.

It is appropriate for the person who made the original entry in a record to make corrections in that record.

TRUE

No one federal law addresses the legal requirements governing all patient records.

TRUE

The DHHS requires, as a Medicare Condition of Participation, that the medical record contain information to justify admission and hospitalization, support the diagnosis, and describe the patient's progress and response to treatment and services.

TRUE

Explain the concept of an amendment to the record under the HIPAA Privacy Rule.

The Privacy Rule provides patients with a right to amend patient-specific health information and sets a minimum standard to follow in allowing amendments to the health record by a patient. This rule requires the health-care provider to respond to the patient that it has made the requested amendment or if the amendment is not made, give written notice to the requestor.

Will civil or criminal liability apply to a health-care institution that destroys a record in other than the ordinary course? Why?

Yes, civil liability generally will apply if the health-care provider accidentally or incidentally discloses health information when destroying a record in the ordinary course. Ordinarily, criminal liability would not apply.

legal health record

business record generated by a healthcare provider that describes an episode of care

authentication

confirming an entry with written signature, initials, or computer-generated code

certificate of destruction

document detailing data and record method of destruction, what, and how

record retention schedule

document detailing retained data and for how long and how.

health record

document that includes a complete, accurate description of a patient's history, condition, and treatment

authorship

identifies healthcare provider who made an entry

hybrid record

record that is part paper-based and part electronic