Chapter 12: Access, Use, and Disclosure/ Release of Health Information

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Access

One of the rights protected by the Privacy Rule, the right of access allows an individual to inspect and obtain a copy of his or her own protected health information that is contained in a designated record set, such as a health record; also an information security term that refers to the ability to enter an electronic system and make use of the data within it

Active record

A health record of an individual who is a currently hospitalized inpatient or an outpatient

Adoption

A legal status in which the parental rights and responsibilities of one set of parents are legally terminated and a new parental relationship is established by law

Age of majority

In most states, the age of 18; an individual generally must have reached the age of majority in order to be considered a competent adult

Americans with Disabilities Act (ADA) 1990

Law that ensures equal opportunity for, and elimination of discrimination against, persons with disabilities

Autopsy

A postmortem examination to determine cause of death

Behavioral health

A broad array of psychiatric services provided in acute, long-term, and ambulatory care settings; includes treatment of mental disorders, chemical dependency, mental retardation, and developmental disabilities as well as cognitive rehabilitation services

Clinical Laboratory Improvement Amendments (CLIA)

A law that provides that clinical laboratories are to disclose test results or reports only to "authorized persons"- unless state law defines them otherwise, defined by the law as the person who orders the test

Competent adult

An individual who has reached the age of majority ad is mentally and physically competent to tend to his or her own affairs; may consent to treatment and may authorize the access or disclosure of his or her health information

Confidentiality of Alcohol and Drug Abuse Patient Records Regulation

Regulation enacted for the purpose of encouraging individuals to seek substance abuse treatment without fear of their health information being disclosed

Court order

A document issued by a judge that compels certain actions, such as testimony or the production of documents such as health records

Disability determination services (DDS)

State agencies responsible for providing to the Social Security Administration medical evidence to determine whether a resident of a state is or is not disabled under the Social Security disability law

Disclosure

The act of making information known; the release of confidential health information about an identifiable person to another person or entity; release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information

Durable power of attorney (DPOA)

A power of attorney that remains in effect even after the principal is incapacitated; can be drafted to take effect only when the principal becomes incapacitated

Durable power of attorney for healthcare decisions (DPOA-HCD)

A legal instrument through which a principal appoints an agent to make healthcare decisions on the principal's behalf in the event the principal becomes incapacitated

Duty to warn

The legal obligation of a health professional to disclose information to warn an intended victim when a patient threatens to harm an individually identifiable victim or victims, and the psychiatrist or other mental health provider believes that the patient is likely to actually harm the individual(s)

Electronic Records Express (ERE)

A program implemented by the Social Security Agency and state Disability Determination Services that enables providers to submit records related to disability claims to a secure website

Emancipated minor

One who is under the age of majority and is self-supporting, and whose parents have surrendered their rights of custody, care, and support

Employee health record

A record kept on an employee as part of employment that contains any and all information related to such items as medical tests, drug tests, examinations, physical abilities, immunizations, screenings required by law, biohazardous exposure, and physical limitations

Fair and Accurate Credit Transactions Act (FACTA)

An act that requires advance employee (i.e., patient) authorization for a consumer reporting agency to share medical information with employers for employment or insurance purposes; it also requires financial institutions and creditors to develop and implement written identity theft programs that identify, detect, and respond to red flags that may signal the presence of identity theft

Freedom of Information Act (FOIA) of 1967

a law covering the rights of disclosure to and access by the public regarding federal agency records

Health Information Exchange (HIE)

Electronic movement of health-related information among organizations within a region or community that facilitates access to and retrieval of clinical data in support of sale, timely, efficient, and effective patient-centered care; an organization or entity that forms to create an electronic framework to connect physicians to pharmacies, hospitals, and other healthcare entities

Health Information handler (HIH)

Organization or entity that handles information on behalf of a provider

Health Information organization (HIO)

An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards

Homeland Security Act

A 2002 act with the goal of preventing terrorist attacks in the United States while reducing the vulnerability of terrorism, minimizing its damages, and assisting in recovery from attacks in the United States; gives government authorities the right to access information needed to investigate and deter terrorism

Human Genome Project

A multiyear project that ended in 2003 in which all human DNA was identified and mapped

Human immunodeficiency virus (HIV)

The virus that causes acquired immunodeficiency syndrome (AIDS)

Incompetent adult

An individual who is at or above the age of majority and becomes incapacitated due to illness or injury, either permanently or temporarily; another person should be designated to make decisions for that individual, including decisions about the use and disclosure of the individual's protected health information

Inpatient

A currently hospitalized patient

Legal guardian

Individual designated by the court system to assume legal responsibility for another individual

Medical emergency

Severe injury or illness (including pain); definition depends on healthcare insurer

Minor

An individual who is under the age of majority (usually 18 years of age) who has not been legally emancipated (declared an adult) by the court

National Human Genome Research Institute (NHGRI)

A division of the National Institutes of Health that discusses the issues and questions around the Human Genome Project and how the information and technology will affect standards of patient care

Next-of-kin

: An individual who, by virtue of his or her relationship to the patient (such as a spouse, adult child, parent, or adult sibling), may make healthcare decisions on the patient's behalf

Noncustodial parent

A parent who does not have custody of a child or children as designated by the court system in cases of divorce or legal separation

Nondisclosure agreement

An agreement relating to the confidentiality and privacy of patient information that employee may be required to sign as a condition of employment

Occupational safety and health record

As part of employment, a record kept on an employee that contains any and all information related to such items as medical tests, drug tests, examinations, physical abilities, immunizations, screenings required by law, biohazardous exposure, and physical limitations

Open records laws

Laws that define what information is subject to public disclosure and are used to deny Freedom of Information Act (FOIA) requests that include protected health information; also known as public records, sunshine law, or freedom of information laws

Outpatient

A patient currently being seen in an ambulatory care, clinic, or physician setting who is not admitted to a hospital as an inpatient

Ownership (of health record, information)

In healthcare, the person to whom the health record belongs (traditionally, the healthcare provider)

Patriot Act

A 2001 law enacted to deter and punish terrorist acts in the United States and around the world and to enhance law enforcement investigations; gives government authorities the right to access information needed to investigate and deter terrorism

Personal representative

A person with legal authority to act on behalf of another individual and who is treated the same as the individual regarding the use and disclosure of the individual's protected health information

Primary data source

(in healthcare) A record developed by healthcare

Privilege statutes

Laws that legally protect confidential communications between a provider (e.g., physician, psychologists, martial therapist) and a patient from disclosure during civil and some criminal misdemeanor litigation

Protected health information (PHI)

A term defined in the HIPAA Privacy Rule as "individually identifiable health information that is transmitted by electronic media, maintained in electronic medium, or transmitted or maintained in any other form or medium"

Psychotherapy notes

Behavioral health notes recorded by a mental health professional that document or analyze the content and impressions of conversations that are part of private counseling sessions; they are not part of the health record and do not contain information such as diagnosis, prescriptions, treatment modalities, and test results

Public records laws

Laws that provide public disclosure upon request of any information of any public body in a state, except as otherwise exempt by state regulations

Regional health information organization (RHIO)

A health information organization that brings together healthcare stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community

Release of information (ROI)

The act of making information known; the release of confidential health information about an identifiable person to another person or entity; release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information; the process of disclosing protected health information from the health record to another party

Secondary data

When data from a record are used for purposes other than what was intended

Social Security Administration (SSA)

A division of the federal government that administers rehabilitation and disability services for people suffering from physical or mental disabilities that affect their ability to work or return to work in a timely manner

Subpoena

Legal order that commands an individual to give testimony or commands the production, inspection, copying, testing, or sampling of books, documents, electronically stored information, or tangible items

Substance Abuse and Mental Health Services Administration (SAMHSA)

A division of the Department of Health and Human Services that, in 2004, published a document explaining the relationship between HIPAA and the Alcohol and Drug Abuse Regulations regarding confidentiality and release of information

Sunshine laws

see Open Records Law, Public records Law: Laws that define what information is subject to public disclosure and are used to deny Freedom of Information Act (FOIA) requests that include protected health information; also known as public records, sunshine law, or freedom of information laws

Syndromic surveillance

refers to monitoring nonspecific clinical information that may indicate a bioterrorism-associated disease before a specific diagnosis is made

Uniform Health-Care Decision Act (UHCDA)

A model law created in 1993 that provides that an individual may give an oral or written instruction to a healthcare provider that remains in force even after the individual loses capacity, and suggests decision-making priority for that individual's surrogates

Use

HIPAA definition with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity hat maintains such information

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