MR 103 - Health Record Law

• define the medico-legal terminology utilized in the course;
• demonstrate understanding of the basic concepts of law and the judicial system;
• identify the differences between a valid subpoena duces tecum and an invalid one;
• given a subpoena duces tecum, accurately describe the steps in dealing with specific types of problem records;
• state the property rights of a medical record;
• describe the legal implications of particular types of records;
• describe the proper method of correcting an error in a medical record;
• identify the retention requirements for medical records as stated by the accreditation agencies, licensing organizations, state law etc.;
• describe the procedure for assuring safe return of an original record, which has been subpoenaed, to court;
• demonstrate understanding of HIPAA;
• state the purpose of and need for confidentiality of incident reports;
• differentiate between personal and impersonal use of the record;
• discriminate between request that require authorization and those that do not;
• describe the reporting requirements for “sensitive” records;
• describe legal status of medical staff committee, QM, UR, minutes;
• describe the components of a legitimate consent;
• identify individuals authorized to give consent;
• given specific policies and procedures for release of patient information correctly respond to the requests;
• discuss: Patient Self Determination Act of 1990, durable power of attorney, health care proxy, living will, DNR orders, health care ethics, advanced directives, EHR and other pertinent issues;
• identify provisions of recently passed or impending legislation that would affect the management of health information and/or health record practice;
• describe the role of regulatory agencies, statutory, and regulatory law, and public health reporting requirements with regard to the use and disclosure of health information;
• demonstrate understanding of the Fraud and Abuse legislation;
• describe the steps in the ROI;
• maintain user access logs/systems to track access to and disclosure of identifiable patient data;
• demonstrate understanding of the Electronic Health Data Submission Standards; and
• describe the key provisions for the HIPAA Privacy Rule and Security Rule to whom they apply, and how they affect access to health information.