Legal Issues in Health Information Management

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Chapter 10 Vocabulary Terms from LaTour

Administrative Law

A body of rules and regulations developed by various administrative entities empowered by Congress; falls under the umbrella of public law

Case Law

Unwritten law originating from court decisions where no applicable statute exists

Circuit

The geographic area covered by a U.S. Court of Appeals

Civil Law

The branch of law involving court actions among private parties, corporations, government bodies, or other organizations, typically for the recovery of private rights with compensation usually being monetary

Common Law

Unwritten law originating from court decisions where no applicable statute exists

Contract Law

A branch of law based on common law that deals with written or oral agreements that are enforceable through the legal system

Controlled Substance Act

The legislation that controls the use of narcotics, depressants, stimulants, and hallucinogens

Court of Appeals

A branch of the federal court system that has the power to hear appeals on the final judgement of district courts

Covered Entity (CE)

To make a good faith effort to obtain the patient's written acknowledgment of receipt of the HIPAA Privacy Notice

Credentialing Process

The process of reviewing and validating the qualifications (degrees, licenses, and other credentials), of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services

Criminal law

A branch of law that addresses crimes that are wrongful acts against public health, safety, and welfare, usually punishable by imprisonment and/or fine

Default Judgement

A court ruling against a defendant in a lawsuit who fails to answer a summons for a court appearance

Defendant

In civil cases, an individual or entity against whom a civil complaint has been filed; in criminal cases, an individual who has been accused of a crime

Designated Record Set

A group of records maintained by or for a covered entity that may include patient medical and billing records; the enrollment, payment, claims adjudication, and cases or medical management record systems maintained by or for a health plan; or information used, in whole or in part, to make patient care-related decisions

E-Discovery

Refers to Amendments to Federal Rules of Civil Procedure and Uniform Rules Relating to Discovery of Electronically Stored Information; wherein audit trails, the source code of the program, metadata, and any other electronic information that is not typically considered the legal health record is subject to a motion for compulsory discovery

Evidence

Something that provides proof

Federal Register

The daily publication of the U.S. Government Printing Office that reports all changes in regulations and federally mandated standards, including HCPCS and ICD-9-CM codes

Felony

A serious crime such as murder, larceny, rape, or assault for which punishment is usually severe

Freedom of Information Act (FOIA)

The federal law, applicable only to federal agencies, through which individuals can seek access to information without the authorization of the person to whom the information applies

Incident

An occurrence in a medical facility that is inconsistent with accepted standards of care

Individually Identifiable Health Information

Personal information that can be linked to a specific patient, such as age, gender, date of birth, and address

Interrogatories

Discovery devices consisting of a set of written questions given to a party, witness, or other person who has information needed in a legal case

Judge-Made Law

Unwritten law originating from court decisions where no applicable statute exists

Jurisdiction

The power and authority of a court to hear and decide specific types of cases

Legal Health Record

The subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to legally permissible requests

Licensure

The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)

Litigation

A civil lawsuit or contest in court

Metatdata

Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information

Misdemeanor

A crime that is less serious than a felony

Motion for Summary Judgement

A request made by the defendant in a civil case to have the case ruled in his or her favor based on the assertion that the plaintiff has no genuine issue to be tried

National Practitioner Data Bank (NPDB)

A data bank established by the federal government through the 1986 Health Care Quality Improvement Act that contains information on professional review actions taken against physicians and other licensed healthcare practitioners, which healthcare organizations are required to check as part of the credentialing process

Negligence

A legal term that refers to the result of an action by an individual who does not act the way a reasonable prudent person would act under the same circumstances

Plaintiff

The group or person who initiates a civil lawsuit

Preemption

In law, the principle that a statue at one level supersedes or is applied over the same or similar statute at a lower level (for example, the federal HIPAA privacy provisions trump the same or similar state law with certain exceptions

Privacy Act of 1974

The legislation that gave individuals some control over information collected about them by the federal government

Privacy Rule

The federal regulations created to implement the privacy requirements of the simplification subtitle of the Health Insurance and Portability Act of 1996

Privilege

The professional relationship between patients and specific groups of caregivers that affects the patient's health record and its contents as evidence; the services or procedures, based on training and experience, that in individual physician is qualified to perform; a right granted to a user, program, or process that allows access to certain files or data in a system

Privileging Process

The process of evaluating a physician's or other licensed independent practitioner's quality of medical practice and determining the services or procedures he or she is qualified to perform

Prosecutor

An attorney who prosecutes a defendant accused for a crime on behalf of a local, state, or federal government

Protected Health Information (PHI)

Under HIPAA, all individually identifiable information, whether oral or recorded in any norm or medium, that is created or received by a healthcare provider or any other entity subject to HIPAA requirements

Request for Production

A discovery device used to compel another party to produce documents and other items or evidence important to a lawsuit

Restitution

The act of returning something to its rightful owner, of making good or giving something equivalent for any loss, damage, or injury

Spoliation

The intentional destruction, mutilation, alteration, or concealment of evidence

Standard of Care

An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines; codes of ethics published by professional associations or societies; regulations for accreditation published by accreditation agencies; usual and common practice of equivalent clinicians or organizations in a geographical regions

Statute of Limitations

A specific time frame allowed by a statute or law for bringing litigation

Statutory (Legislative) Law

Written law established by federal and state legislatures

Tort

An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm

Trier of Fact

The judge or jury hearing a civil or criminal trial

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