HIT 101 - CH 9, CH 8,

DPOA-HVD Healht care decisions

, an individual whiel STILL COMPETENT, designates another person (PROXY) to make healthcare decisions consistent with the individuals whishes and ehave.

Legal health record distinction

- it is important to an org business and leagal process -because the legal health record is the record that is produced upon request, including legal requests it become important to make sure that the record is legally sound and defensible as a valid document in legal situations. Specific Data. DRS and EHR are MORE expansive than the LHR

HIM professional -legal aspect regarding health records includes:

-Compilation, maintenance and retention of health records -Ownership and control of health records, including use and disclosure -Defining the legal health record **HIMs may also be involved in the medical staff credentialing process as well as organizational licensure, certification an accreditation.

Litigation Process- Third step Complaint response

-Denying -Admitting -Pleading to ignorance to the allegations -Bringing a countersuit (counterclaim) against a third party (joiner) or against another defendant (cross-Claim)

Advance directive three type of document specifying a persons specific wishes: -

-Durable power of attorney for healthcare decision (DPOA-HCD) -A living Will -Do-Not-Resuscitate (DNR) JACHO-accredited org are required to implement policies regarding advance directives and DNR orders.

Health Record guidelines according to AHIMA:

-Health record should be organized systematically to facilitate the retrieval and compilation of data. -Only be documented by persons authorized by the hospitals policies and medical rules and regulations -Hospital policy and medical staff rules and regulations should specify who may receive and transcribe an MD verbal orders. -Record entries should be documented at the time the treatment was describe is rendered. -Authors of all entries should be clearly identifiable -Abbreviations and symbols should be used in the health record ONLY when approved by hospital and medical staff bylaws and per regulations. JACHO contains a list of prohibited abbreviations that the facilities bust consider. -All entries in the health record should be permanent. -To correct errors or make changes in the paper health record, a single line should be drawn in ink through the incorrect entry. *The word ERROR should be printed at the top of the entry along with a legal signature or initials. *Electronic record corrections are particularly important because courts have historically viewed their integrity as SUSPECT.. Thus the procedures must be developed to control check and track changes made to data housed in the EHR. In particular changes must be transparent so a court is satisfied that they cannot be done surreptitiously and without traceable evidence change. -If a patient wishes to change information in his or her health record, the change should not be made to the original entry but rather should be made as an ADDENDUM (or Amendment). *the changes should be clearly identified as an additional document appended to the original health record at the request of the patient. Under HIPAA the patient is allowed for amendment to his or her EHR, but the provider may be allowed to deny the request change.

DUrable

means that the document is in effect when the individual is no long competent.

Negligence

occurs when a healthcare provider doe snot do what a prudent person would normally do in similar circumstance.

Certification -

of individuals is a designation given by a private org to acknowledge a requisite level of knowledge, competencies and skills. May either be mastery level or entry level ENtry LEvel: RHIA - registered health information administrator RHIT - registered health information technologist MAster Level: CHPS - certified in healthcare privacy and security CHDA - Certified health data analysis CCS - certified coding speciality

Consents: Definition

ones agreement to receive medical treatment. IT can be: -written, (Preferred because it offers proof) -spoke; (communicated through words) -expressed or implied. (through conduct)

Jurisdiction

(n.) an area of authority or control; the right to administer justice. *The authority of the court to hear a case. **Health record of an individual who is party to a legal proceeding is usually admissible in litigation or judicial proceedings provided it is material or relevant to the issue. Either a court order or a subpoena are used to obtain the health information.

Statute of Limitations - health records

* period of time in which a lawsuit must be filed. Health records must be kept in its original form coinciding with the statute of limitations for that state.

Legalities

**Health record of an individual who is party to a legal proceeding is usually admissible in litigation or judicial proceedings provided it is material or relevant to the issue. Either a court order or a subpoena are used to obtain the health information. Responses to the court order and subpoenas depend on the state regulations. Some state allows copies of health records be certified and mailed to the clerk where some states only allows in person submissions of the health record.

Negligence Lawsuit

**to be successful, the plaintiff must provide four elements: 1) the existence of duty to meet a standard of care (degree of caution expected of an ordinary and reasonable person under given circumstances) 2) Breach or deviation form that duty 3) Causation, the relationship between the defendants conduct and the harm that was suffered 4) Injury (harm), which may be economic (medical expenses and loss of wages) or non-economic (pain and suffering).

EHR charting changes

*Electronic record corrections are particularly important because courts have historically viewed their integrity as SUSPECT.. Thus the procedures must be developed to control check and track changes made to data housed in the EHR. In particular changes must be transparent so a court is satisfied that they cannot be done surreptitiously and without traceable evidence change.

Disclosures without patient authorization

*May be required under specific state statutes. For instance in: -Reporting vital statistics (BIrth and death) -other public health safety or welfare situations i.e. STD spread, injuries from firearms, knives, or from other violent criminal activity. Treatment of suspected victims of child abuse or neglect.

health record -Organizations compilation and maintenance

-State laws -Federal Laws -Organizations : i.e. JACHO, AHIMA -Third -party payers **Taking into consideration all these rules and regulations the healthcare org establish their own requirements to ensure the UNIFORMITY of health record format and content. **Using the form of erg policies and procedures as well as medical staff practices

Appeal court or Supreme Court

-These trials are no "Reenactments." Legal documents are prepared by each partys attorney, who argue the merits of the case before a panel of appellate courts. **Appeals are designed nearly exclusively to address legal errors or problems alleged to have occurred at the lower court, by they are not meant to address the facts of the case again.

personal health record (PHR)

An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care *Owned and manged by the individual who is the subject o the record.

Implied Contract

A contract formed in whole or in part from the conduct of the parties. **are created by the parties behaviors (i.e. a patients arrival at a MD office)

CMS (Centers for Medicare and Medicaid Services)

A division responsible for developing a replacement for ICD-9 CM Volume 3 procedures codes An agency within the cabinet-level HHS (Department of Human and health Services)

health record -compilation and maintenance

A health record can be defined as written or graphic information documenting facts and events during the rendering of patient care. Either paper or electronic format. **Health record entries and records, dictated by best practices, states that they must be in their entirety be COMPLETE, ACCURATE AND TIMELY.

Mediation Under Judicial Decision

A method of settling disputes outside of court by using the services of a neutral third party, called a mediator. The mediator acts as a communicating agent between the parties and suggests ways in which the parties can resolve their dispute. **Parties agree to submit a dispute to a third party facilitator, who assists the parties in reaching an agreed-upon resolution.

Privileged communication

A protection for patient confidentiality. *generally prohibit medical practitioners from disclosing information arising from the parties professional relationship and relating to the patients care and treatment. *If patients WAVE their privilege, the medical providers is NOT prohibited from making disclosures.

Advance Direction

A special type of consent that communicates persons wished to be treated or if person should become unable to express on his or health behalf.

Bench Trial

A trial in which a judge alone hears a case (no jury). is a trial by judge, as opposed to a trial by jury. The term applies most appropriately to any administrative hearing in relation to a summary offense to distinguish the type of trial

Administrative Law

A type of public Law. The Executive branch of government responsible for enforcing laws enacted by the legislative branch. Administrative agencies which are part of the EXECUTIVE branch , develop and enforce rules and regulations that carry out the intent of statutes ie. HHS developed rules and regulations to carry out the intent of the HIPAA statute, and it has the power to enforce them. (under Administrative Law) FDA within HHS, the power to develop rules that control the manufacture of drugs. ***The LEGISLATIVE branch of the federal govt has given a number of administrative agencies the power to establish regulations.

1. CONSENTS: play an important role in documenting individuals wishes regarding the healthcare they will receive

Advance Directive: are important in documenting the persons end-of-life decisions.

Health Record- custodians

As a legal custodian, the org is responsible to ensure that it maintains its integrity and the heath record is kept secure.

1 which of the following actions by the health records custodian affirms the legitimacy of the health record

Authentication

Executive Branch

Branch of government, headed by the President, that enforces the laws comprises of the president and staff, namely cabinet-level agencies ie. CMS (centers for Medicare and Medicaid Services) HHS (Department of Human and health Services)

Subpoena

Compels a response a response in a legal proceedings Two main types: -Subpoena as testificandum: is a court summons to appear and give oral testimony for use at a hearing or trial. The use of a writ for purposes of compelling testimony -Subpoena decus tecum: or subpoena for production of evidence) is a court summons ordering the recipient to appear before the court and produce documents or other tangible evidence for use at a hearing or trial.

1 *** No medical liability for breach of contract can exist WITHOUT a physician--patient relationship

Compliance with legal requirements for appropriate use and disclosure must be ensured as must adherence to the professions ethical principle.

Testifying - HIM

Considered as the custodian of the record. Custodians are called as a witness by one party or the other to testify as to the authenticity of a record sought as evidence. Testifying as to a records authenticity means the record custodians is verifying that it contains information about the individual in question, was completed in the usual course of business, and is reliable and truthful as evidence. Parties may also agree upon allowing a photocopy of the record or a printed version of the electronic health record (EHR) to be introduced into evidence rather than the original.

Legislative Branch

Consists of the US Congress and is comprised of the House of Reps and the Senate who creates statutory law (statutes)

Sources of Public and Private Law

Constitutional, Statutory, Administrative, Judicial (Common Law/Case Law)

Statutory law (statutes)

Created by the legislative branch (Congress) i.e. Medicare and HIPAA statute law is written law set down by a body of legislature or by a singular legislator (in the case of an absolute monarchy). This is as opposed to oral or customary law; or regulatory law promulgated by the executive or common law of the judiciary. Statutes may originate with national, state legislatures or local municipalities

Litigation Process- fourth step Discovery

Discovery is where parties use various strategies to obtain information about a case prior to trials and determine the strength of an opposing party's case. 2 common types of Discovery methods: - Depositions: which obtains ones out-of-court testimony under oath - Subpoena: (an associated discovery tool) which compels a response in a legal proceeding.

Metadata

Data that describes other data. F or example, a digital image may include metadata that describe the size of the image, number of colors, or resolution. *data about data and include information that track actions such as when and by whom a document was accessed or changed.

Constitutional Law

Defines the amount and types of power and authority governments are given. The US constitution defines and sets forth the powers of the 3 branches of the Federal Govt', which are also found in the State Govt: -Legislative -Executive -Judicial Branch (The court system) Each state constitution is the supreme law of that state, but it is subordinate to the US constitution, Supreme Law of the nation.

1 True or False: The Joint Commission sets the official record retention standards for hospitals and other healthcare facilities.

False

Statutes

Forms Statutory Law Enacted by legislative bodies. US Congress and state legislatures are legislative bodies . Local bodies, such as municipalities, also can enact statutes, sometimes referred to as ordinances.

Judicial Decision (Common Law/case law)

Fourth source of law created from court (judicial) decisions. Courts interpret statutes, regulations and constitution an resolve individual conflicts. Main source of PRIVATE Law.

Tort Liability

Healthcare providers also can be held responsible for professional Tort Liability., When they harm another person.

General Jurisdiction Trial Courts

Hear cases of a general nature that are not within the jurisdiction of limited-jurisdiction courts Record and store testimony and evidence. Courts that hear any civil or criminal cases that have not been assigned to a special court. *Hear more serious criminal cases or civil cases involving larger sums of money.

Health Record Changes - per patient request

If a patient wishes to change information in his or her health record, the change should not be made to the original entry but rather should be made as an ADDENDUM (or Amendment). *the changes should be clearly identified as an additional document appended to the original health record at the request of the patient. Under HIPAA the patient is allowed for amendment to his or her EHR, but the provider may be allowed to deny the request change.

Causes of Action

In civil lawsuits, the allegation that the harm suffered by the plaintiff (victim) was a direct and proximate result of the defendant's behavior. i.e. Breach of Contract Intentional Tort negligence **Theories INDER WHICH LAWSUITS ARE BROUGHT THAT ARE RELATED TO PROFESSIONAL LIABILITY.

Private Law (Civil Law)

Involves rights and duties among private entities or individuals. Get its main source of laws from the JUDICIAL decision. i.e. when a contract for the purchase of a house is written between two parties. Covers: contracts property torts (injuries) civil actions Medical often applies when there is a breach of contract or when a tort occurs through malpractice

Public Law

Involves the government at any level and its relationship with individuals and org. Purpose: is to define, regulate and enforce rights where any part of a govt agency is a party. Most common type: Criminal law Also Covers: -COP (Medicare Conditions of Participation): the requirement set forth for healthcare providers who accept Medicare patients -Criminal Actions -Civil Actions -Administrative Law

1. Autonomy

It is an established right in the US individuals generally have the right of autonomy over their own bodies. Included in this right is the right of individuals to make their own health care decisions provided that they are not legally incompetent.

Litigation Process- fifth step Trial

Jury Selection: Jury selection through the process of VOIR Dire . If a jury is waived, a judge heas the case called a bench trial. Evidence is presented. The plaintiffs attorney is first to call witness and present evidence. In turn. the defendants attorney call witnesses and presents evidence. ** Typically, in both health-related and non-health related cases that involve records as evidence, the record custodian is called as a witness by one party or the other to testify as to the authenticity of the records sought as evidence.

Tort Law

Law that deals with harm to a person or a person's property. **Is broad and include non-healthcare related acts (ie. when some one goes through a red light and strikes another rvehicle) or health related acts (a nurse administers the wrong medication).

"record released upon a valid request"

Legal health record

Informed Consent

Needed when a treatment or procedure becomes progressively more risky or invasive. Form must be completed to ensure the patient has a basic understanding or treatment of diagnosis along with the risks of the treatment or procedures. Usually a process and it is the responsibility of the who will provide who will be rendering the treatment or procedures or performing the procedure . **Failure toe obtain the consent can laterally result legal action against them baised on NEGIGENCE.

Negligence : 3 types

Nonfeasance: failure to act, such as not ordering a standard diagnostic test Malfeasance: a wrong or improper act, such as removal of the wrong body part Misfeasance: improper performance during an otherwise correct act, such as nicking the bladder during an otherwise appropriately performed gallbladder surgery.

Health Record - Access

Patients and other legitimately interested third parties have the right to access them. Associated with control is the issue of patients access to ones own health records. State Law and HIPAA grants individuals the right to access their protected health information with some exceptions. Patient portals have become more available and use is encouraged by providers the right of access is changing.

health record - Third-party payers -compilation and maintenance

Play an important role in the maintenance and content of health records. Payers have often have specific requirements about content that must be present in the health record in order for reimbursement to occur. Failure to comply by external entities will likely result in some type of penalty such as loss of licensure or accreditation, nonpayment of claims or fines.

Health Record

Primary function is document patient treatment and provide a means for a patients healthcare providers to communicate among each other. Also plays an important role for the LHR (legal health record) Other functions include assisting in assigning diagnoses, assisting in choosing treatment. ***Health record contains the who, what, when, where, why and how.*** Provides critical evidence in the legal process, medical malpractice, and other personal injury lawsuit, criminal cases, health fraud, etc.

Tort

Professional liability actions are brought against health care providers because of the tort of : Negligence Unintentional wrongdoing

health record - State Laws -compilation and maintenance

Requirements for compiling and maintaining health records are usually found in state rules and regulations. -Develop by admin agencies responsible fir licensing healthcare org, many often specify only that health records be complete and accurate.

health record - Federal Laws -compilation and maintenance

Requirements for maintaining health records include the Medicare Conditions of participation contain which contain specific requirements that must be satisfied by healthcare org that treat Medicare or Medicaid patients .

Do Not Resuscitate (DNR)

Specifies a persons wish NOT to receive treatment (specifically CPR). Most often used by the elderly or in chronically ill health, it directs healthcare providers to refrain from performing the otherwise standing order of CPR in case of cardiac and respiratory arrest. State law provides the framework for completeing the DNR orders and forms JACHO-accredited org are required to implement policies regarding advance directives and DNR orders.

1 The source of law that is created by legislative bodies is which of the following?

Statute

US Constitution

Supreme Law of the nation.

Judicial Branch (Supreme Court)

The court systems Interprets laws passed by the legislative branch.

Breach of Contract

The failure, without legal excuse, of a promisor to perform the obligations of a contract. ** When the relationship between patient and physician does exists, the physicians failure to diagnose and treat the patient with reasonable skill and care may cause the patient to sure the MD for Breach of Contract.

Legal health record (LHR)

The form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization's legal health record varies depending on how the organization defines it **The record used for legal purposes and is the "record released upon a valid request" it can be stored on any medium and its contents is defined by the ORG rather than by law.

Health record ownership

The generally accepted principle that individual health records are maintained and owned by the healthcare organization that creates them. But that patients have certain rights of control over the release of patient-identifiable (confidential) information **Although patients often believe they own their health record and do, in fact own the information in it, ultimate responsibility for the physical health record still rests with the org.

Advance Directive

The lack of advance directives can result in legal battles regarding the undocumented wishes of individuals who become legally incompetent. i.e. highly publicied end-of-life cases: -Karen ann Quinlan -Nancy Cruzan -Terri Schiavo

Alternative Dispute Resolution (ADR) Under Judicial Decision

The resolution of disputes in ways other than those involved in the traditional judicial process. Purpose: is to lighten court dockets and provide less costly and time-consuming alternatives of parties to settle their differences Negotiation, mediation, and arbitration are forms of ADR.

Trial Courts (District Courts)

These are divided into courts of limited jurisdiction and hear cases pertaining to a particular subject or involve crimes of lesser severity or civil matters of lower dollar amounts.

1 Which of the following spells out the powers of the three branches of the federal government?

US Constitution

Electronic Health Record (EHR)

a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual. Contains Metadata considered more expansive than the LHR>

Accreditation

a designation bestowed by the American Psychological Association on psychological training programs that meet acceptable training standards. generally viewed as the highest level of competence and standard. JACHO is the most prevelent accredeting body. AOA and the AAAHC for ambulatoery health CARF (commision on accreditation of rehab facilities) for rehabilitaion centers.

Litigation Process- First step Filing complaint.

a legal action to determine a decision in court. Many malpractice cases are negotiated and settled out of court. In order to prepare for judicial decision as the ultimate outcome of a legal proceeding (litigation): 1) a plaintiff initiates a lawsuit against a defendant by filing a complaint in the court, which outlines the defendants alleged wrongdoing. 2) After it is filed, a copy of the complain is served to the defendant along with a SUMMONS. 3) The summons and complaint give the defendant notice of the lawsuit of the lawsuit and to what it pertains to and informs the defendant that the complain must be answered or some other action action. 4) If the defendant fails to answer the complaint tor take other actions, the court grants the plaintiff a judgement of default.

Litigation Process- Second step Summons

a notice directing someone to appear in court to answer a complaint or a charge.

Malfeasance:

a wrong or improper act, such as removal of the wrong body part

AUthentication

affirms a records legitimacy through testimony or written validation. used by custodians of the health records.

Designated Record Set (DRS)

any item, collection, or grouping of information that includes protected health information and is maintained by a covered entity term specific to HIPAA. **MORE expansive than the Legal health Record

Nonfeasance:

failure to act, such as not ordering a standard diagnostic test

Health information purpose

has a variety of purposes from: from provisions off direct patient care to use by outside entities such as insurance and pharmaceutical companies and those uses and disclosure must be appropriated.

Health Record - Disclosure

how health information is disseminated externally

Health Record - USE

how information is used internally

health record - Accrediting bodies -compilation and maintenance

i.e. JCHO standards relate to information management through its: Information Management (IM) record Care, treatment, and services (RC) chapters. Acute care, long tern care, home health, and behavioral health providers, among others, must follow these standards if they are to be accredited by JACHO. i.e. AHIMA which published best practices information

Misfeasance:

improper performance during an otherwise correct act, such as nicking the bladder during an otherwise appropriately performed gallbladder surgery.

Litigation Process- Part of Second step Judgement in default

is a binding judgment in favor of either party based on some failure to take action by the other party. Most often, it is a judgment in favor of a plaintiff when the defendant has not responded to a summons or has failed to appear before a court of law. The failure to take action is the default. The default judgment is the relief requested in the party's original petition.

VOIR Dire

is a process of jury de-selection designed to eliminate those individuals who have some inherent characteristic that blocks them from considering the facts necessary to appreciate your story. Additionally, get a transcript of a previous voir dire conducted by opposing counsel.

Physician--patient relationship

is established by either an implied contract or an express contract .

A living Will

is executed by competent adult , expressing the individuals wishes regarding treatment should the individual become afflicted with certain condition and no longer able to communicate on his or her own behalf. i.e. persistent vegetative state or terminal condition. Addresses extraordinary life-saving measures such as ventilator support and either the continuation or removal or nutrition and hydration.

Medical Malpractice

is the professiona liability of healthcare providers--physicians, nurses, therapists or other involved in the delivery of the patient care.

Contract

is usually created by the mutual agreement of the parties involved--in this case by the patient and MD mutually agree to contract termination, the patient dismisses the physician, or the physician withdraws from providing care for the patient.

DNR process

prior to executing a DR the patient and the MD should have a discussion , a CONSENT form should be signed by the patient and he MD writes an order in the patients health record stating as such.

Retention standards AHIMA - health records

routinely published recommendations on the retention of health records. Health retention schedules: -Are designed to meet an org needs so that health information is available for not only patient care, but also research education, and to meet the legal requirements that apply to the org. -Should be specific about the retention of information, including a description of what information is to b kept, for how long it is to kept and the medium on which it will be stored -Clearly specify in it policies and procedures the destruction method that is to be used for each medium on which health information is housed.

Arbitration Under Judicial Decision

settling a dispute by agreeing to accept the decision of an impartial outsider. * Parties agree to submit a dispute to a third party to make to make a decision. Part of the Alternative Dispute Resolution

1 Which of the following are laws enacted by a legislative body?

statutes

Expressed Contracts

the terms of the agreement are fully and explicitly stated in words, oral or written **Articulate, either in writing or verbally (a patients written or verbal agreement to treatment)

Three-Tier structure Federal and State

three-tier consists of : Trial Courts (lowest Court) - District courts in the federal system) Court of Appeal (also called appellate courts): that hears appeals on final judgment of the trial court Supreme Court (highest court)Hears final appeals from intermediate court of appeals

General Consent

used from a patient for routine treatment and failure to d so can result in a legal treatment and failure to do so can results in legal action; generally for battery or harmful or offensive contact

Tort - intentional

where an individual purposely commits a wrongful act that results in injury.