Legal and Ethical Aspects of Health Information Management, Fifth Edition
By Dana C Mcway, Jd, Rhia and Fahima
Contents:
Preface xv
PART 1 STUDY OF THE LAW IN GENERAL 1
1 Workings of the American Legal System 2
Learning Objectives 2
Key Concepts 2
Private And Public Law 3
Private Law 3
Public Law 5
Sources Of Law 6
Constitution 6
Statutes 8
Administrative Decisions And Regulations 10
Judicial Decisions 12
Branches Of Government 14
Legislative Branch 16
Executive Branch 16
Judicial Branch 17
Quasi-Legal Requirements 17
Conclusion 18
Case Study A 18
Case Study B 18
Review Questions 19
Enrichment Activity 19
2 Court Systems and Legal Procedures 21
Learning Objectives 21
Key Concepts 21
Court Systems 22
Jurisdiction 22
Court Structure 23
Legal Process 28
Beginning The Lawsuit 29
Discovery 29
Pretrial Conference 40
Trial 40
Appeal 41
Satisfying The Judgment 42
Alternative Dispute Resolution 42
Conclusion 44
Case Study 44
Review Questions 44
Enrichment Activity 45
3 Judicial Process of Health Information 46
Learning Objectives 46
Key Concepts 46
Health Records As Evidence 47
Hearsay 48
Privilege 49
Exclusions 50
Responses To Legal Process 50
Subpoenas 51
Court Orders 51
Discovery Requests 53
Warrants 55
Response Methods 56
Conclusion 59
Case Study 59
Review Questions 59
Enrichment Activity 60
4 Principles of Liability 62
Learning Objectives 62
Key Concepts 62
Health Care Relationships 63
Physician–Patient Relationships 64
Hospital–Patient Relationships 64
Hospital–Physician Relationships 65
Theories Of Liability 66
Nonintentional Torts 67
Intentional Torts 75
Breach Of Contract 77
Social Media 78
Defenses And Limitations On Liability 79
Statutes Of Limitations 79
Charitable Immunity 80
Governmental Immunity 80
Good Samaritan Statutes 81
Contributory And Comparative Negligence 81
Assumption Of Risk 82
Apologies 82
Conclusion 82
Case Study 83
Review Questions 83
Enrichment Activities 84
PART 2 AN OVERVIEW OF ETHICS 87
5 Ethical Standards 88
Learning Objectives 88
Key Concepts 88
Ethical Models 89
Ethical Concepts 90
Ethical Theories 96
Conclusion 99
Case Study 99
Review Questions 99
Enrichment Activity 99
6 Ethical Decisions and Challenges 100
Learning Objectives 100
Key Concepts 100
Ethical Decision Making 101
Influencing Factors 101
Ethical Decision-Making Process 109
Ethical Challenges 111
Generalized Challenges 111
The Role Of Ethics In Supervision 113
Health Care Challenges 115
Health Information Management Challenges 116
Conclusion 118
Case Study A 118
Case Study B 119
Review Questions 119
Enrichment Activity 120
Websites Addressing Codes Of Ethics 120
7 Bioethics Issues 121
Learning Objectives 121
Key Concepts 121
Related To The Beginning Of Life 122
Family Planning 122
Abortion 124
Perinatal Ethics 125
Eugenics 126
Related To Sustaining Or Improving The Quality Of Life 126
Hiv/Aids 126
Organ Transplantation 128
Genetic Science 129
Related To Death And Dying 130
Planning For End Of Life 131
Euthanasia 132
Withholding/Withdrawing Treatment 133
Conclusion 133
Case Study 133
Review Questions 134
Enrichment Activity 134
PART 3 LEGAL AND ETHICAL ISSUES CENTRAL TO
HEALTH INFORMATION MANAGEMENT 135
8 Patient Record Requirements 136
Learning Objectives 136
Key Concepts 136
Function And Use Of The Health Record 137
Legal Requirements For Health Record Content 139
Content Of The Health Record 139
Timely And Complete Health Records 143
Retention Requirements 148
Statutes And Regulations 149
Other External Forces 150
Bases For Decision 152
Record Destruction 152
Destruction In Ordinary Course 152
Destruction Due To Ownership Change 154
Destruction Due To Closure 155
Conclusion 156
Case Study 156
Review Questions 157
Enrichment Activities 157
9 Confidentiality and Informed Consent 160
Learning Objectives 160
Key Concepts 160
Confidentiality 161
Constitutional Basis 163
Statutory Basis 163
Common Law Basis 165
International Basis 165
Confidentiality Application 165
Confidentiality In The Research Context 168
Confidentiality Of Hiv Information 169
Informed Consent 172
Historical Development 172
Scope Of Informed Consent Doctrine 173
Situations Requiring Informed Consent 176
Conclusion 177
Case Study 177
Review Questions 177
Enrichment Activities 178
10 Access to Health Information 181
Learning Objectives 181
Key Concepts 181
Ownership Of Health Information 182
Notice Of Use And Disclosure 184
Access By Or On Behalf Of The Patient 192
General Principles Of Disclosure Of Information 192
By The Patient 195
To Third Parties 197
Reasonable Fees 198
Access By The Researcher 200
The Ethical Perspective 200
The Regulatory Perspective 201
Access By The Business Associate 204
Access Pursuant To Reporting Laws 206
Access To Adoption Records 207
Unlawful Access 208
Conclusion 210
7 Bioethics Issues 121
Learning Objectives 121
Key Concepts 121
Related To The Beginning Of Life 122
Family Planning 122
Abortion 124
Perinatal Ethics 125
Eugenics 126
Related To Sustaining Or Improving The Quality Of Life 126
Hiv/Aids 126
Organ Transplantation 128
Genetic Science 129
Related To Death And Dying 130
Planning For End Of Life 131
Euthanasia 132
Withholding/Withdrawing Treatment 133
Conclusion 133
Case Study 133
Review Questions 134
Enrichment Activity 134
PART 3 LEGAL AND ETHICAL ISSUES CENTRAL TO HEALTH INFORMATION MANAGEMENT 135
8 Patient Record Requirements 136
Learning Objectives 136
Key Concepts 136
Function And Use Of The Health Record 137
Legal Requirements For Health Record Content 139
Content Of The Health Record 139
Timely And Complete Health Records 143
Retention Requirements 148
Statutes And Regulations 149
Other External Forces 150
Bases For Decision 152
Record Destruction 152
Destruction In Ordinary Course 152
Destruction Due To Ownership Change 154
Destruction Due To Closure 155
Conclusion 156
Case Study 156
Review Questions 157
Enrichment Activities 157
9 Confidentiality and Informed Consent 160
Learning Objectives 160
Key Concepts 160
Confidentiality 161
Constitutional Basis 163
Statutory Basis 163
Common Law Basis 165
International Basis 165
Confidentiality Application 165
Confidentiality In The Research Context 168
Confidentiality Of HIV Information 169
Informed Consent 172
Historical Development 172
Scope Of Informed Consent Doctrine 173
Situations Requiring Informed Consent 176
Conclusion 177
Case Study 177
Review Questions 177
Enrichment Activities 178
10 Access to Health Information 181
Learning Objectives 181
Key Concepts 181
Ownership Of Health Information 182
Notice Of Use And Disclosure 184
Access By Or On Behalf Of The Patient 192
General Principles Of Disclosure Of Information 192
By The Patient 195
To Third Parties 197
Reasonable Fees 198
Access By The Researcher 200
The Ethical Perspective 200
The Regulatory Perspective 201
Access By The Business Associate 204
Access Pursuant To Reporting Laws 206
Access To Adoption Records 207
Unlawful Access 208
Conclusion 210
Case Study A 210
Case Study B 211
Review Questions 211
Enrichment Activities 212
11 Specialized Patient Records 216
Learning Objectives 216
Key Concepts 216
Drug And Alcohol Abuse 217
Confidentiality 218
Release Of Information 219
Miscellaneous Issues 225
Mental Health And Developmental Disability Care 226
Content Requirements 226
Privacy Restrictions 228
Home Health Care 230
Genetic Information 231
Hiv Information 234
Background Information About Hiv/Aids 234
Testing 235
Conclusion 237
Case Study 237
Review Questions 237
Enrichment Activities 238
PART 4 SPECIALIZED AREAS OF CONCERN IN HEALTH INFORMATION MANAGEMENT 243
12 Risk Management, Quality Management, and Utilization Management 244
Learning Objectives 244
Key Concepts 244
RISK MANAGEMENT 245
General Principles 245
Patient Record Requirements 246
Incident Reports 250
Trends in Risk Management 254
QUALITY MANAGEMENT 256
Peer Review Privileges 256
Medical Staff Disciplinary Process 257
Utilization Management 260
Historical Development 261
Utilization Review 262
Conclusion 263
Case Study 264
Review Questions 264
Enrichment Activities 265
13 Information Systems 267
Learning Objectives 267
Key Concepts 267
Electronic Health Records 268
Legal Health Record 269
Accreditation and Licensure Issues 270
Liability Issues 272
Hipaa Security Rule 281
Breaches 283
Internet 285
Electronic Mail and Text Messaging 286
Digital Imaging 287
Telemedicine 288
Future Legal And Ethical Trends In Information Technology 290
Data and Privacy 290
Digital Access 291
Conclusion 292
Case Study 292
Review Questions 292
Enrichment Activities 293
14 Health Care Fraud and Abuse 296
Learning Objectives 296
Key Concepts 296
Fraud And Abuse 297
Major Laws Addressing Fraud and Abuse 297
Law Enforcement Agencies 302
Compliance Programs 304
Conclusion 308
Case Study A 308
Case Study B 308
Review Questions 308
Enrichment Activity 309
15 Law and Ethics in the Workplace 310
Learning Objectives 310
Key Concepts 310
Employment 311
Employee Rights 312
Overview 312
Employment Law Application 319
Social Media 330
Ethics Application 331
Conclusion 333
Case Study 333
Review Questions 333
Enrichment Activity 334
APPENDICES 335
Appendix A: Table of Cases 336
Appendix B: List of Common Acronyms 344
Appendix C: Selected Laws Affecting HIM 349
Appendix D: The Patient Care Partnership 351
Glossary 352
Index 371
Online Web Appendices (Login.Cengage.Com)
Appendix E: Sample HIPAA Privacy Notices
Appendix F: Durable Power of Attorney for Health Care and Health Care Directive