48 terms

Legal Issues in Health Information Management

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
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
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
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
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
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
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
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
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
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)
A civil lawsuit or contest in court
Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information
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
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
The group or person who initiates a civil lawsuit
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
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
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
The act of returning something to its rightful owner, of making good or giving something equivalent for any loss, damage, or injury
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
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