1,278 terms

LEGAL 1-8 COMPREHENSIVE

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Who has the legal right to refuse treatment?
Juanita, who is 98 yrs old and of sound mind, Linda, who is 35 incompetent, and created a Living Will prior to becoming incompetent stating that she did not wish to be kept alive artificial mean.
Janice arrives at her physician's office for her 10:30 scheduled appointment and pays her office visit co-payment. Her physician examines her. Based on these facts, Janice's consent is
implied
Mary is contemplating triple bypass surgery. Informed consent by her surgeon would typically contain which of the following
Purpose of proposed procedure, risks assocated wth the procedure, non invasive treatment alternatives
Mary Little is 95 yrs old, While an inpatient at Gen. Hospital, she agrees that she doesnt want to be resuscitated if she would have a cardiopulmonary arrest. She sings a form and the physician documents it in the record. This best describes a
DNR order
An advance directive is used to direct an individual's healthcare wishes in the event of
Patient incapacitation
When a competent adult refuses treatment, a court may be required to balance the individual's privacy interests against
The governments interest in protecting human life
carrying out the wishes stated in a living will applies to whch of the following patient's who is incompetent due to illness?
a 40yr old man who was born with severe mental retardation
Emergences are an exception to the consent requirement for
both adults and minors
The Uniform Health-Care Decisions Act ranks the next of Kin n the following order for medical decision making purposes
spouse; adult child; parent ; adult sibling
Johnny is 12, his parents are divorced. In order for Johnny to receive medical treatment, generally
one parent must consent
Mrs. Baker, who is a competent adult, has consulted her phys. For chronc URQ pain. Her phys. Recommends an elective cholestcystectomy. In this case, who must consent to the operative procedure?
Mrs. Baker
the medical staff at Regency health is nationally revowned for its skill in performing cardac procedures. The nursing staff in the cardiac unit has noticed a signifcant lack of informed consents prior to performance procedures. Obtaining informed consent is the responsiblity of the
Physician
Consent forms that allow for the performance of routine services by healthcare providers are
general consents
in the Cruzan case, the court held that a person cannot assume end of life decisions on behalf of an incompetent person without _______ evidence that the person would refuse the continuation of life sustaining treatment.
clear and convincing
What is the primary purpose of patient health information?
patient care
Who is responsible for ensuring the quality of health record documentation?
provider
Which of the following statements about the "legal health record" or the "designated record set" is incorrect?
designated record set is determined by the medical staff
Of the following, which is the most likely to happen to the the health records of a phys. Patient when a phys. Leaves an office practice?
retained by the practice
Once a paper health record has been converted onto microfilm, the info cannot be used as evidence. T/F
False
The legal health record
will be disclosed upon request
The legal health record must meet requirements as defined by the following
federal regulations, state laws, accreditation body standards
Verbal Orders by telephone or in person are discouraged. In cases where verbal orders are necessary, which of the following is the most effective method by which the risk of miscommunication can be lessened?
person receiving the order should read iit back to insure that the order is correct
Which of the following exemplifes an acceptable patient record entry?
patient articulated pain level as a 6
Staff disagreements within the health record should be
avoided
Mrs. Bolton is an angry patient who resents her phys. "bossing her around" refuese to take a portion of the medications that the nurses brng to her pursuant ot phys. Orders., and is verybally abusive to the patient care assistants. Of the following options, the most appropriate way ot document Mrs.Bolton;'s behavior in the medical record is
non compliant and hostile toward staff
legally, whch of the following is the most important in determining the length of time that a hospital must retain medical records?
statute of limitations
Integrity refers to the
accuracy and completeness of information
A goal of E_SIGN legislation was to
give electronic signatures in all business meetings
Auto Authentication
contradicts basic authentication standards
Authentication methods include
handwritten signature, rubber signature stamp, electronic signature
Changes to health record entries
are acceptable in certain circumstances
Printing paper Documents from an HER systems
creates legal challenges as to which document is the source of truth
Which of the following personnel should be authorizes, per hospital policy, to take a physician's verbal order for the administration of medication?
nurse working on the unit where the patient is located
A late entry into the health record should
be identified as a late entry
Abbreviations in the health record
should have only one meaning
The integrity of E H R documentation is more susceptible than the paper health record to which of the following functions?
cut and paste
Record maintenance and contect requirements are established in part by
dept of health and human services, joint commission, centers for medicare and medicaid services
Dr. Harvey has changed a piece of data in a patient record. The info that tracks this change and enables a jury to see this change in a medical malpractice action is called
metadata
Of the following, who has ultimate legal responsibility for the quality of care rendered in a healthcare organization?
governing body
Discovery method that includes written questions that must be answered by potential witness
interrogatories
state appellate court will hear a case dealing with an injury to a patient if the attorney appealing the case can prove
an error of law occurred
when served with a court order directing the release of health records, an individual
must comply with it
defendent fails to respond to a plaintiffs complaint, this may result in
default judgment
following step should NOT be in health info dept procedure for preparing records in response to a subpoena
remove pages containing detrimental info
from an evidentiary standpoint, incident reports
should not be placed in the patients health record
medical record of kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wishes to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the
business records exception
E-discovery rules are amendments to the _____ and were created in response to the tremendous volume of evidence, maintained in electronic format that is pertinent to lawsuits
federal rules of civil procedure
Relevant eveidence
tends to make the existance of a fact more or less probable
authentication of the record refers to
establishment of its trustworthiness
environmental service employee of the hosp was called to the vascular surgery floor to clean the floor where a bag of potassium chloride spilled. after cleaning the floor, the employee failed to place a sign about a wet floor. mrs jones, a hosp visitor fell on the floor and got hurt. she incurred med expense of $560. and lost wages of $1000. she brought suit and the jury awarded her $1560, representing reimbursement of the med expenses and lost wages, plus $10k for jurors perceived recklessness on the part of the hosp. what is the $10k considered?
punitive damages
HIM professional may attend leagal proceedings and testify as to
authenticity of patients health record
hosp employee destroyed a health record so that its contents-which would be damaging to the employee- could not be used at trial. In legal terms the employees action constitutes
spoliation
plaintiffs attorney has filed a state-law complaint in fed court. this is an error of what nature?
procedural law
gloria kramer files a med malpractice lawsuit against dr johnson alleging that he committed negligence in the treatment of her diabetes. ms. kramers attorney insists that dr johnson can't speak about her med diagnosis becuase of physician-patient privilege. ms. kramers attorney
is incorrect because she placed her med condition at issue
per the theory of physician/patient privilege, the right to waive the confidentiality of med info belongs to the
patient
metadata is
info about an electronic record
patient-privilege is defined by
state law
subpoena duces tecum compels the recipient to
bring records to a legal proceeding
defendant does not pay the damages awarded against her in a lawsuit. the court may order the seizure of a portion of her monthly wages to satisfy the judgment in an action called
garnishment
if a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be followed in determining the case is
stare decisis
collection of fed statutes is found in a
code
concept of confidentiality applies to
all data and info systems
automated paper and verbal communications
clinical, financial and business records
what is the intermediate court in the tiered structure of the state court system in nearly every state?
appellate court
appellate courts are called ________ in federal court system
circuit courts
regulations written by the state dept of health of US dept of health and human svcs are examples of
administrative law
what law(s) involve govt as one of the parties?
public law and criminal law
principle of law that serves as a guide in similar subsequent cases is called
precedent
when a dispute is submitted to disinterested 3rd party and the 3rd party settles the case, this is
arbitration
In the US, both the federal and state court systems us a _____ tier approach
three
judicial decision may be based on the following types of actions
disputes between individuals
challenges to the constitutionality of a statute
legislative act passed by congress is an example of
statutory law
what is the legal term used to define the protection of health info in the patient-provider relationship
confidentiality
law based on judicial decision is called
common law
mary has gone to her dr to discuss a med condition, what legal term best describes the type of communication that has occured between them
priviledged communication
health info privacy has been established in all but one way
constitutional right
custodian of health records refers to the individual within an organization is responsible for what action
authorized to certify records
supervise the inspection and copying of record
testifies to the authenticity of records
term used to describe a patient has the right to maintain control over certain personal info is referred to as
privacy
what is the term used to physical and electronic protection of health information
security
what is also known as case law
judicial law
party that presents evidence to disprove or disprove wrongdoing is the
defendant
criminal law is a type of
public law
US code is
statutory law
under the concept of stare decisis
lower courts look to higher courts
fed court has legal control over cases involving federal statutes. this legal contol is referred to as
jurisdiction
this legal doctrine limits excessive litigation by prohibiting subsequent lawsuits about the same matter and involving the same parties once a decision has been made and all appeals have been exhausted
res judicata
one restriction involving diversity jurisdiction is
no plaintiff can be from the same state as any of the defendants
what court is the lowest court in the tiered structure of the state court system in nearly every state
trial court
legislative act passed by congress is an example of
statutory law
centers for disease control and prevention is located in the US
dept of health & human services
federal court system, appellate courts are called
circuit courts
legal matter was tried at the district court level and appealed to a fed appellate court. the case was appealed to the US supreme court, which declined to hear it. when the supreme court declined the case it
denied cert
med malpractice appeal brought by carol agains mercy hosp has just concluded. the court reached a decision in favor of the hosp. the courts written determination that outlined the facts of the case and the legal theories followed to reach its outcome is an
opinion
federal trial courts are called
district courts
lawsuit is brought against a govt in
court of claims
appellate courts hear appeals on final judgments of
trial court decisions
US congress follows the model
bicameral
agency that is heavily involved in combating medicare & medicaid fraud is
inspector general for health & human services
in general, if virginia and texas laws conflict
each state follows its own law
one or more advantages of mediation over utilizing the court system to resolve a dispute are
time saving
cost saving
increase privacy
deeming authority has been granted by the US dept of HHS to the
american osteopathic assoc
authority of TJC is mostequivalent to that of the
commission of accreditation of rehab facilities
health information privacy protection has been established in court decisions, federal laws, state laws, but not
constitutional rights
who owns the health record
provider who generated the info
what is the term used most often to describe the indiv within an org who is responsible for protecting health info in conjuction with the court system
custodian of record
many laws address patient privacy and confidentially. what other resourses address the providers resp for keeping health info private
professional code of ethics
when someone is identified as an information steward, the indiv is resp for what activities
integrity of electronic health record
protecting loss or destruction of electroinic health record
security of record
courts rules that guide a lawsuit from beginging to end is
procedural law
class action lawsuits often involve
groups of consumers against large entities
legal proceedings that accompany a lawsuit is
litigation
dr huffman has been sued by a patient, he brings in the manufacturer as defendant. this process is
joinder
service is
notification of a lawsuit
process that allows evidence to be used in a court of law and considered by a jury is
admissibility
mary has been deposed via a subpoena duces tecum. as the HIM director of hosp, she will bring the health record of a patient. her role is
authenticate the records validity
court orders for the production of records
do not require patient authorization
subpoena
may be issued by a partys attorney
forma, written objections to subpeonas are often made in a
motion to quash
when removing a health record in response to a subpoena duce tecum or a court order, what should be completed
an index of contents
bench trial refers to a trial
without a jury
excusal of a juror without a stated reason is
peremptory challenge
the burdon of proof in which a plaintiff must prove that it was more likely than not that each element of a case was met is
compensatory damages
actual damages, which compensate a plaintiff for losses incurred are
compensatory
what type of damage is collected by implementing monetary caps to couteract lavish jury awards
non-economic compensatory
party who appeals a trial court decision is
appellant
if a plaintiff incurs $30k in damages realted to a medical expense and lost wages, what are these
economic compensatory damages
mrs black sued mr brown for failing to return the clock. mr brown ignured mrs blacks lawsuit and she won a judgment of $1000. the court encumbered mr browns property so that when he tried to sell it 3 years later, he was unable to take any profit from the sale until mrs black was first pait this is
judgment lien
when mr brown ignored mrs blacks lawsuit she won the case under what legal theory
default judgment
dr howard is called to testify in a med malpractice case against dr hale. he testifies that base on his expertise of the subject matter. dr dale didnt commit med malpractice. dr howard is a/an
expert witness
when an indiv represents herself as her own attorney she is
acting pro se
when a patient discovers that a sponge has been left in his abdomen, the patient brings a lawsuit. to do this the patient must document and serve his allegations to the surgeon in a legal document called
complaint
lawsuit has been filed against a hosp for bodily injuries allegedly suffered by a patient. legal counsel for the hosp believes the injuries are exaggerated. he used what discovery method to determine the true extent of the injuries
physical exam
whether or not information may be introduced formally into evidence at trial is called
admissibility
per the theory of physician/patient privilege, the right to waive the confidentiality of medical info belongs to the
patient
metadata is
info about electronic record
legal hold
is issued by a court if there is concern about destruction of info during litigation
authenticiation of a record refers to
establishment of its baseline trustworthiness
health record is representative of what type of evidence
demonstrative evidence
best evidence rule
permits copies to be substituted in certain cercumstances
from an evidentiary standpoint, incident reports
should not be placed in a patients health record
during a trial to determiine wheither dr smith was liable for medical malpractice, dr smith testified in his own defense. legally, dr smiths testimony was
direct evidence
relevant evidence
tends to make theexistence of a fact more or less probable
patient-provider privelege is defined by
state law
medical record is admitted into evidence as an exception to what rule
hearsay
HIM professional may attend legal proceedings and testify to
authenticate the health record
subpoena duces tecum compels the recipient to NOT do;
serve on a jury
answer a complaint
produce documents
what is issued by the court if there is concern that info may be destroyed iin cases of current or potential litigation
legal hold
statement made to an attorney, psychologist or clergy that is protected from being revealed even in court is what type of communication
privileged
when determining whether or not evidence should be admissible in a court proceeding, the judge bases his discision on
best evidence rule
hearsay exception
business records exception
when determining whether or not health records are privileged, the HIM professional should refer to
state statutes
what is not a difference between electronic and paper records
confidentiality
what employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed
computer forensics
during hospitalization, mrs jones went into shock. hot water bags and other restoratives were ordered by attending physician. because the temp of water bags was too high, and not checked by the nurse, mrs jones suffered painful and permanent injuries. in this instance who may be sued under the doctrine of respondent superior
hospital
what type of damages have been primary targets of tort reform legislation
non-economic compensatory damages
what is the term to denote a cause of action when a physician fails to perform with reasonable skill and care
negligence
if the court allows the plaintiff to only recover damgages to the extent (percentage) he was responsible for harm, what defense has the court applied to its final judgment
comparative negligence
scalpal was left in a ptient during an exploratory aparotomy. additional surgery was required to remove the scalpel. based on the facts, what rule applies
res ipse loquitur
unlawful intusion on an individual is considered
invasion of privacy
burden of proof usually falls upon the plaintiff, except in case which apply the principle of
res ipsa loquitur
what term denotes the suspension of the start of the statute of limitations clock
tolling
the most likely cause of action from intentional touching by a healthcare provider, without patients consent is
battery
conduct which places a person in reasonable apprehension of being touched in a manner that is insulting , provoking or physically injurious is
assault
patient sued for negligent care. dr smith produced evidence showing that the patients poor medical outcome was due to the patients failure to follow his treatment plan and take the meds. if a court refuses to grant the patient any money damages because the patients actions contributed to the harm, what defense has the court applied to its final judgment
contributory negligence
statute of limitations generally refers to
period of time within which a lawsuit must be brought
patient is treated in er for laceration of the foot. the patient is given written instructions by the dr to have the sutures out in 3 days which the patient fails to do. an infection ensues resulting in permanent damage to the foot. the patient sues the surgeon for negligence and the surgeon uses the er record to prove what type of defense
contibutory negiligence
what is a valid defense to a claim of defamation
info was not published to a third party
info was spoken only , it was not in writing
communication was privileged because it was an issue of public safety
assault and battery fall under the category of
intentional tort
what elements must be present in order for damages in a negligence action be awarded
injury, duty to care, breach of duty, causation
proximate cause is based on whether or not it was ___ that the defendants breach of duty ould cause harm
forseeable
johnny died as a result of an adverse reaction to meds given during surgery at mercy hosp, a joint commission accredited facility. the hosp had consistently failed to enforce TJC stancdards requiring the presence of a complete history and physical exam on the patients chart prior to surgery. because of the absence of a history and physical exam on the patients chart and the info it would have contained regarding drug allergies, the hosp may be found to have committed
breach of duty
during a hearing to determint workers comp benefits for tom, his med records from dr loop revealed that tom is HIV+. this info had been entered into toms chart erroneously and was informormation about another patient. Tom is not HIV+. Tom filed a defamation lawsuit against dr loop and his physician practice. what will be the most likey outcome
no defamatiion on liability because of the absolute privlege defense
most likely successful cause of action resulting from intentional touching by a healthcare provider w/o patients consent is
batter
which elements must be present in order for damages in a negligence action to be awarded
injury, duty of care, breach of duty, causation
assault and battery falls under the category of
intentional tort
what type of damages have been primary targets of tort reform legislation
noneconomic compensatory damages
what are the 2 types of causation necesary to meet the causation element of negligence
actual and proximate
if a court allows the plaintiff to only recover damages to the extent he was not responsible for the harm, what defense has the court applied to its final judgement
comparative negligence
intentional confinement of an individual against his wishes may be legally defensible if
a mentally ill patient is a danger to self and others
an indiv has a dangerous contagious disease
although a couse of action for false impreonment may result if a hosp retains a patient against their will, a hosp may be protected from liability if the patient
is a danger to himself or others
has a highly contagious disease
hosp is held liable in its own right for the harm that the physicians on its medical staff couase to a patient, the legal theory being applied is
respondeat superior
what is an artificial being created per state statutory authority
corporation
what characterizes a corporation
it is separate from its owners or incorporators
it can sue or be sued
it can continue to exist despite an owners death
piercing the corporate veil refers to
holding corporation owners liable for bad acts
not for profit corp may
pay reasonable salaries to its employees
bylaws
are the internal rules of an organization
not for profit corp that is formed for a charitable purpose
must meet irs established criteria to be tax exempt
fiduciarty duty includes
duty of loyalty
duty of responsibility
ultra vires acts are those that
exceed a corporations powers
general hosp is a 1000 bed facility. mercy hosp is a 100 bed facility. they join to form one corp, which is named general hosp. the restructuring that has most likely occured is a
acquisition
contracts
must contain an offer and acceptance
physician has been found to have breached his contract with a patient through abandonment. as a remedy, the court may order the following
compensatory damages
term used to describe standard contract terms is
boilerplate
learned intermediary defense used by HIT vendors, who is the learned intermediary
physician
what is not a federal antitrust law
HIPPA
What are federal antitrust laws
sherman act
clayton act
federal trade commission act
when two or more entities at different levels in a distribution chain act together to restrain trade, this is
vertical restraint of trade
what act offers both civil and criminal penalties
sherman act
what actions related to the medical staff might raise antitrust issues
excluding entire class of practitioners from medical staff membership
economic credentialing
may be associated with physicians who have an ownership in competing hospitals
may be based on a perceived loss of loyalty by a physician
may be associated with a review of a physicans volume of cases
noncompete agreements
might violate antitrust law
what is NOT a defense for nonperformance of a contract
specific performance
what is a defense for nonperformance of a contract
fraud
mistake of fact
duress
what characterizes a joint venture
created for a specific purpose
designed to have a limited lifespan
publicly held corp
generally has thousands of shareholders
what describes a responsibility of corps governing board members
appointing medical staff members
what is NOT a required element for piercing the corporate veil
corp is a not for profit entity
what is a required element for pierceing the corporate veil
complete domination of the corp by its owners
control by owners was used to perpetrate a wrongful act
corp control was the proximate cause of injury
challenges to tax exempt corps operating with a charitable purpose inclue
aggressive billing practices
insufficient charity care provided
inflated billing practices toward the uninsured
legal health record must meet requirements as defined by
federal regulations
state laws
accreditation body standards
once the paper has been converted to microfild or scanned into electronic record, the info cannot be used as evidence
false
gold of E-sign legislation was to
give electronic signatures increased legal standing
mary is 95, while an inpatient at general hosp she agrees she doesnt want to be resuscitated if she would have a cardiac arrest. she signs a form and the physician documents it in the record this is
DNR order
janice arrives at her physicians office for her appt and pays her office visit co-pay. her dr examines her. based on these facts janices consent is
implied
auto-authentication
contradicts basic authentication standards
cruzan case, the court held that a person cannot assume end of life decisions on behalf of an incompetent person without ___ evidence that the person would refuse the continuation of life sustaining treatment
clear and convincing
what is the primary or most important use of patient health info
patient care
dr harvey has changed a piece of datea in the patients record. the info that tracks this change and enables a jury to see this change in a med malpractice action is called
metadata
printing paper documents for an EHR system
creates legal challenges asto which document is the source of truth
advance directive is used to direct individuals health care wishes in the event of
patient incapacitation
late entry into the health record should
be identified as a late entry
record maintenance and content requiremenet are established in part by
NY state doh
TJC
CMS
patient self determiniation act requires health care providers to
inform patients of their right to creat advance directives
document the presence or absence of advanced directives in the patient health record
abbreviations in the health record
should have only one meaning
what is most likely to happen to the health records of a physicians patient when a physician leaves an office practice
retained by the practice
mary is contemplating triple bypass surgery. informed consent by her surgeon would typically contain what elements
purpose of the proposed procedure
risks associated with the procedure
non invasive treatment alternatives
staff disagreements within the health record should be
avoided
mrs bolton is an angry patient who resents her dr "bossing her around". she refuses to take meds the nurse bring to her pursuant to drs orders and is verbally abusive to patient care assts. what is appropriate way to document her behavior in the record
noncompliant and hostile toward staff
emergencies are a exception to the consent requrement for
adults and minors
mrs davis is preparing to undergo hernia repair sugery . who should obtain the informed consent
the surgeon doing the surgery
changes to health record entries
are indicative of negligent care
legally, what is most important in determing the length of time that a hosp must retain records
statute of limitations
uniform health care decision acts ranks next of kin for adults in what order for medical decision making
spouse, adult child, parent, adult sibling
Johnny is 12 and his parents are divorced. in order for johnny to receive medical treatment, who can consent
one parent must consent
physician who performs a surgical procedure on a patient without obtaing consent may be liable for
battery
consent that is conveyed through spken or written words is
express
consent that is conveyed through a persons conduct is
implied
indiv is in an emergency condition and does not have capacity to communicate consent
consent is implied by law
patient signs a consent form ,authorizing hsop staff to perform interventions necessary for overall medical care. this consent is
general
informed consent requires informing the patient of
nature and purpose of proposed treatment
risks and benefits of proposed treatment
alternatives to proposed treatment
proposed med intervention is related to a research study
institutional review board approval is required
laws that require drivers to consent to blood alcohol tests, with penalties for refusal, probably exist to
protect the public
under the common rule, informed consent for human subjects in research studies may be waived if
the institutional review board approves a waiver
GINA applies to
health insurers
group health plans
employers with 15 or more employees
GINA
prohibits discrimination based on genetic info
under HIPAA, compound authorizations
combine informed consent with authorization for use and disclosure of a research subjects health info
advance directives
provide a way for physicians to ensure that life saving treatment is given, regardless of an indivuals wishes
if it is not durable, a POA is effective
only when the principle has capacity
living will
expresses an indiv healthcare wishes when specific health conditions exist
do not resuscitate order
is a type of advance directive
is used only in emergency situations
may be revoked at any time
uniform anatomical gift act
promotes consistency among state laws
provides suggested standards for all aspects of organ donation
includes an opt in system for organ donation
when a competent adult refuses to consent to lifesaving treatment , the two competing sets of interest that come into play are the indiv privacy interest and
the governments interest in protecting and preserving human life
re quinlan the court held that
an incompetent indiv has a right of privacy to terminate treatment
cruzan case, the missouri supreme court held that no one can make end of life choices on behalf of an incompetent person w/o
clear and convincing evidence
end of life controversy in the terri schiavo case included
a question about teh authority of legislative bodies to intervene in judicial matters
uniform health care decisions act
provides an additional option to creating advance directives
emancipated minors are defined as those who have
been afforded legal status as an adult
state laws most likely permit a monir to consent on their own behalf for
alcohol addiction
frances has been experience abdominal pain. removal of her gallbladder has been recommended. who is resp to obtain her informed consent
the physician who will perform the surger
uniform photographic copies of business and public records as evidence act does what
allows record reproductions to be admited as evidence
legal health record or designated record set is
designated record set is defined by HIPAA legislation
legal health recores is defined by the facility
legal health record my not include all of the info in the designated record set
destruciton of health records
may be a prudent business practice
legal health record
is the record that is disclosed upon request
verbal orders by phone or in person are discouraged. in cases where verbal orders are necessary, what is the most effective method by which the risk of miscommunication can be lessened
person receiving order should read it back to insure the order is correct
integrity referes to
accuracy and completeness of info
authentication methods include
handwritten signature
rubber stamp signature
electronic signature
integrity of EHR documentation is more susceptible that paper health record to what function
cut and paste
who has ultimate legal responsibility for the quality of care rendered in a healthcare org
governing body
what act served to make electronic transactions as enforeable as paper
uniform electronic transactions act
countersignature
signifies review and evaluation of the first providers entry
error in a paper health record should be
crossed out so that it can be seen but not relied on
personal health record
may be housed in a system that a provider owns and controls
Discovery method that includes written questions that must be answered by potential witness
interrogatories
a state appellate court will hear a case dealing with an injury to a patient if the attorney appealing the case can prove
an error of law occurred
when served with a court order directing the release of health records, an individual
must comply with it
a defendent fails to respond to a plaintiffs complaint, this may result in
default judgment
the following step should NOT be in health info dept procedure for preparing records in response to a subpoena
remove pages containing detrimental info
from an evidentiary standpoint, incident reports
should not be placed in the patients health record
the medical record of kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wishes to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the
business records exception
E-discovery rules are amendments to the _____ and were created in response to the tremendous volume of evidence, maintained in electronic format that is pertinent to lawsuits
federal rules of civil procedure
Relevant eveidence
tends to make the existance of a fact more or less probable
authentication of the record refers to
establishment of its trustworthiness
an environmental service employee of the hosp was called to the vascular surgery floor to clean the floor where a bag of potassium chloride spilled. after cleaning the floor, the employee failed to place a sign about a wet floor. mrs jones, a hosp visitor fell on the floor and got hurt. she incurred med expense of $560. and lost wages of $1000. she brought suit and the jury awarded her $1560, representing reimbursement of the med expenses and lost wages, plus $10k for jurors perceived recklessness on the part of the hosp. what is the $10k considered?
punitive damages
a HIM professional may attend leagal proceedings and testify as to
authenticity of patients health record
a hosp employee destroyed a health record so that its contents-which would be damaging to the employee- could not be used at trial. In legal terms the employees action constitutes
spoliation
a plaintiffs attorney has filed a state-law complaint in fed court. this is an error of what nature?
procedural law
gloria kramer files a med malpractice lawsuit against dr johnson alleging that he committed negligence in the treatment of her diabetes. ms. kramers attorney insists that dr johnson can't speak about her med diagnosis becuase of physician-patient privilege. ms. kramers attorney
is incorrect because she placed her med condition at issue
per the theory of physician/patient privilege, the right to waive the confidentiality of med info belongs to the
patient
metadata is
info about an electronic record
patient-privilege is defined by
state law
a subpoena duces tecum compels the recipient to
bring records to a legal proceeding
a defendant does not pay the damages awarded against her in a lawsuit. the court may order the seizure of a portion of her monthly wages to satisfy the judgment in an action called
garnishment
if a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be followed in determining the case is
stare decisis
the collection of fed statutes is found in a
code
the concept of confidentiality applies to
all data and info systems
automated paper and verbal communications
clinical, financial and business records
what is the intermediate court in the tiered structure of the state court system in nearly every state?
appellate court
appellate courts are called ________ in federal court system
circuit courts
regulations written by the state dept of health of US dept of health and human svcs are examples of
administrative law
what law(s) involve govt as one of the parties?
public law and criminal law
a principle of law that serves as a guide in similar subsequent cases is called
precedent
when a dispute is submitted to disinterested 3rd party and the 3rd party settles the case, this is
arbitration
In the US, both the federal and state court systems us a _____ tier approach
three
judicial decision may be based on the following types of actions
disputes between individuals
challenges to the constitutionality of a statute
a legislative act passed by congress is an example of
statutory law
what is the legal term used to define the protection of health info in the patient-provider relationship
confidentiality
law based on judicial decision is called
common law
mary has gone to her dr to discuss a med condition, what legal term best describes the type of communication that has occured between them
priviledged communication
health info privacy has been established in all but one way
constitutional right
the custodian of health records refers to the individual within an organization is responsible for what action
authorized to certify records
supervise the inspection and copying of record
testifies to the authenticity of records
the term used to describe a patient has the right to maintain control over certain personal info is referred to as
privacy
what is the term used to physical and electronic protection of health information
security
what is also known as case law
judicial law
the party that presents evidence to disprove or disprove wrongdoing is the
defendant
criminal law is a type of
public law
the US code is
statutory law
under the concept of stare decisis
lower courts look to higher courts
a fed court has legal control over cases involving federal statutes. this legal contol is referred to as
jurisdiction
this legal doctrine limits excessive litigation by prohibiting subsequent lawsuits about the same matter and involving the same parties once a decision has been made and all appeals have been exhausted
res judicata
one restriction involving diversity jurisdiction is
no plaintiff can be from the same state as any of the defendants
what court is the lowest court in the tiered structure of the state court system in nearly every state
trial court
a legislative act passed by congress is an example of
statutory law
the centers for disease control and prevention is located in the US
dept of health & human services
In the federal court system, appellate courts are called
circuit courts
a legal matter was tried at the district court level and appealed to a fed appellate court. the case was appealed to the US supreme court, which declined to hear it. when the supreme court declined the case it
denied cert
a med malpractice appeal brought by carol agains mercy hosp has just concluded. the court reached a decision in favor of the hosp. the courts written determination that outlined the facts of the case and the legal theories followed to reach its outcome is an
opinion
federal trial courts are called
district courts
a lawsuit is brought against a govt in
court of claims
appellate courts hear appeals on final judgments of
trial court decisions
the US congress follows the model
bicameral
an agency that is heavily involved in combating medicare & medicaid fraud is
inspector general for health & human services
in general, if virginia and texas laws conflict
each state follows its own law
one or more advantages of mediation over utilizing the court system to resolve a dispute are
time saving
cost saving
increase privacy
deeming authority has been granted by the US dept of HHS to the
american osteopathic assoc
the authority of TJC is mostequivalent to that of the
commission of accreditation of rehab facilities
health information privacy protection has been established in court decisions, federal laws, state laws, but not
constitutional rights
who owns the health record
provider who generated the info
what is the term used most often to describe the indiv within an org who is responsible for protecting health info in conjuction with the court system
custodian of record
many laws address patient privacy and confidentially. what other resourses address the providers resp for keeping health info private
professional code of ethics
when someone is identified as an information steward, the indiv is resp for what activities
integrity of electronic health record
protecting loss or destruction of electroinic health record
security of record
a courts rules that guide a lawsuit from beginging to end is
procedural law
class action lawsuits often involve
groups of consumers against large entities
the legal proceedings that accompany a lawsuit is
litigation
dr huffman has been sued by a patient, he brings in the manufacturer as defendant. this process is
joinder
service is
notification of a lawsuit
the process that allows evidence to be used in a court of law and considered by a jury is
admissibility
mary has been deposed via a subpoena duces tecum. as the HIM director of hosp, she will bring the health record of a patient. her role is
authenticate the records validity
court orders for the production of records
do not require patient authorization
a subpoena
may be issued by a partys attorney
forma, written objections to subpeonas are often made in a
motion to quash
when removing a health record in response to a subpoena duce tecum or a court order, what should be completed
an index of contents
a bench trial refers to a trial
without a jury
excusal of a juror without a stated reason is
peremptory challenge
the burdon of proof in which a plaintiff must prove that it was more likely than not that each element of a case was met is
compensatory damages
actual damages, which compensate a plaintiff for losses incurred are
compensatory
what type of damage is collected by implementing monetary caps to couteract lavish jury awards
non-economic compensatory
the party who appeals a trial court decision is
appellant
if a intiff incurs $30k in damages realted to a medical expense and lost wages, what are these
economic compensatory damages
mrs black sued mr brown for failing to return the clock. mr brown ignured mrs blacks lawsuit and she won a judgment of $1000. the court encumbered mr browns property so that when he tried to sell it 3 years later, he was unable to take any profit from the sale until mrs black was first pait this is
judgment lien
when mr brown ignored mrs blacks lawsuit she won the case under what legal theory
default judgment
dr howard is called to testify in a med malpractice case against dr hale. he testifies that base on his expertise of the subject matter. dr dale didnt commit med malpractice. dr howard is a/an
expert witness
when an indiv represents herself as her own attorney she is
acting pro se
when a patient discovers that a sponge has been left in his abdomen, the patient brings a lawsuit. to do this the patient must document and serve his allegations to the surgeon in a legal document called
complaint
a lawsuite has been filed against a hosp for bodily injuries allegedly suffered by a patient. legal counsel for the hosp believes the injuries are exaggerated. he used what discovery method to determine the true extent of the injuries
physical exam
whether or not information may be introduced formally into evidence at trial is called
admissibility
per the theory of physician/patient privilege, the right to waive the confidentiality of medical info belongs to the
patient
metadata is
info about electronic record
a legal hold
is issued by a court if there is concern about destruction of info during litigation
authenticiation of a record refers to
establishment of its baseline trustworthiness
a health record is representative of what type of evidence
demonstrative evidence
the best evidence rule
permits copies to be substituted in certain cercumstances
from an evidentiary standpoint, incident reports
should not be placed in a patients health record
during a trial to determiine wheither dr smith was liable for medical malpractice, dr smith testified in his own defense. legally, dr smiths testimony was
direct evidence
relevant evidence
tends to make theexistence of a fact more or less probable
patient-provider privelege is defined by
state law
the medical record is admitted into evidence as an exception to what rule
hearsay
the HIM professional may attend legal proceedings and testify to
authenticate the health record
a subpoena duces tecum compels the recipient to NOT do;
serve on a jury
answer a complaint
produce documents
what is issued by the court if there is concern that info may be destroyed iin cases of current or potential litigation
legal hold
a statement made to an attorney, psychologist or clergy that is protected from being revealed even in court is what type of communication
privileged
when determining whether or not evidence should be admissible in a court proceeding, the judge bases his discision on
best evidence rule
hearsay exception
business records exception
when determining whether or not health records are privileged, the HIM professional should refer to
state statutes
what is not a difference between electronic and paper records
confidentiality
what employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed
computer forensics
during hospitalization, mrs jones went into shock. hot water bags and other restoratives were ordered by attending physician. because the temp of water bags was too high, and not checked by the nurse, mrs jones suffered painful and permanent injuries. in this instance who may be sued under the doctrine of respondent superior
hospital
what type of damages have been primary targets of tort reform legislation
non-economic compensatory damages
what is the term to denote a cause of action when a physician fails to perform with reasonable skill and care
negligence
if the court allows the plaintiff to only recover damgages to the extent (percentage) he was responsible for harm, what defense has the court applied to its final judgment
comparative negligence
a scalpal was left in a ptient during an exploratory aparotomy. additional surgery was required to remove the scalpel. based on the facts, what rule applies
res ipse loquitur
unlawful intusion on an individual is considered
invasion of privacy
the burden of proof usually falls upon the plaintiff, except in case which apply the principle of
res ipsa loquitur
what term denotes the suspension of the start of the statute of limitations clock
tolling
the most likely cause of action from intentional touching by a healthcare provider, without patients consent is
battery
conduct which places a person in reasonable apprehension of being touched in a manner that is insulting , provoking or physically injurious is
assault
a patient sued for negligent care. dr smith produced evidence showing that the patients poor medical outcome was due to the patients failure to follow his treatment plan and take the meds. if a court refuses to grant the patient any money damages because the patients actions contributed to the harm, what defense has the court applied to its final judgment
contributory negligence
the statute of limitations generally refers to
period of time within which a lawsuit must be brought
a patient is treated in er for laceration of the foot. the patient is given written instructions by the dr to have the sutures out in 3 days which the patient fails to do. an infection ensues resulting in permanent damage to the foot. the patient sues the surgeon for negligence and the surgeon uses the er record to prove what type of defense
contibutory negiligence
what is a valid defense to a claim of defamation
info was not published to a third party
info was spoken only , it was not in writing
communication was privileged because it was an issue of public safety
assault and battery fall under the category of
intentional tort
what elements must be present in order for damages in a negligence action be awarded
injury, duty to care, breach of duty, causation
proximate cause is based on whether or not it was ___ that the defendants breach of duty ould cause harm
forseeable
johnny died as a result of an adverse reaction to meds given during surgery at mercy hosp, a joint commission accredited facility. the hosp had consistently failed to enforce TJC stancdards requiring the presence of a complete history and physical exam on the patients chart prior to surgery. because of the absence of a history and physical exam on the patients chart and the info it would have contained regarding drug allergies, the hosp may be found to have committed
breach of duty
during a hearing to determint workers comp benefits for tom, his med records from dr loop revealed that tom is HIV+. this info had been entered into toms chart erroneously and was informormation about another patient. Tom is not HIV+. Tom filed a defamation lawsuit against dr loop and his physician practice. what will be the most likey outcome
no defamatiion on liability because of the absolute privlege defense
the most likely successful cause of action resulting from intentional touching by a healthcare provider w/o patients consent is
batter
which elements must be present in order for damages in a negligence action to be awarded
injury, duty of care, breach of duty, causation
assault and battery falls under the category of
intentional tort
what type of damages have been primary targets of tort reform legislation
noneconomic compensatory damages
what are the 2 types of causation necesary to meet the causation element of negligence
actual and proximate
if a court allows the plaintiff to only recover damages to the extent he was not responsible for the harm, what defense has the court applied to its final judgement
comparative negligence
intentional confinement of an individual against his wishes may be legally defensible if
a mentally ill patient is a danger to self and others
an indiv has a dangerous contagious disease
although a couse of action for false impreonment may result if a hosp retains a patient against their will, a hosp may be protected from liability if the patient
is a danger to himself or others
has a highly contagious disease
if a hosp is held liable in its own right for the harm that the physicians on its medical staff couase to a patient, the legal theory being applied is
respondeat superior
what is an artificial being created per state statutory authority
corporation
what characterizes a corporation
it is separate from its owners or incorporators
it can sue or be sued
it can continue to exist despite an owners death
piercing the corporate veil refers to
holding corporation owners liable for bad acts
a not for profit corp may
pay reasonable salaries to its employees
bylaws
are the internal rules of an organization
a not for profit corp that is formed for a charitable purpose
must meet irs established criteria to be tax exempt
fiduciarty duty includes
duty of loyalty
duty of responsibility
ultra vires acts are those that
exceed a corporations powers
general hosp is a 1000 bed facility. mercy hosp is a 100 bed facility. they join to form one corp, which is named general hosp. the restructuring that has most likely occured is a
acquisition
contracts
must contain an offer and acceptance
a physician has been found to have breached his contract with a patient through abandonment. as a remedy, the court may order the following
compensatory damages
a term used to describe standard contract terms is
boilerplate
in the learned intermediary defense used by HIT vendors, who is the learned intermediary
physician
what is not a federal antitrust law
HIPPA
What are federal antitrust laws
sherman act
clayton act
federal trade commission act
when two or more entities at different levels in a distribution chain act together to restrain trade, this is
vertical restraint of trade
what act offers both civil and criminal penalties
sherman act
what actions related to the medical staff might raise antitrust issues
excluding entire class of practitioners from medical staff membership
economic credentialing
may be associated with physicians who have an ownership in competing hospitals
may be based on a perceived loss of loyalty by a physician
may be associated with a review of a physicans volume of cases
noncompete agreements
might violate antitrust law
what is NOT a defense for nonperformance of a contract
specific performance
what is a defense for nonperformance of a contract
fraud
mistake of fact
duress
what characterizes a joint venture
created for a specific purpose
designed to have a limited lifespan
a publicly held corp
generally has thousands of shareholders
what describes a responsibility of corps governing board members
appointing medical staff members
what is NOT a required element for piercing the corporate veil
corp is a not for profit entity
what is a required element for pierceing the corporate veil
complete domination of the corp by its owners
control by owners was used to perpetrate a wrongful act
corp control was the proximate cause of injury
challenges to tax exempt corps operating with a charitable purpose inclue
aggressive billing practices
insufficient charity care provided
inflated billing practices toward the uninsured
the legal health record must meet requirements as defined by
federal regulations
state laws
accreditation body standards
once the paper has been converted to microfild or scanned into electronic record, the info cannot be used as evidence
false
a gold of E-sign legislation was to
give electronic signatures increased legal standing
mary is 95, while an inpatient at general hosp she agrees she doesnt want to be resuscitated if she would have a cardiac arrest. she signs a form and the physician documents it in the record this is
DNR order
janice arrives at her physicians office for her appt and pays her office visit co-pay. her dr examines her. based on these facts janices consent is
implied
auto-authentication
contradicts basic authentication standards
in the cruzan case, the court held that a person cannot assume end of life decisions on behalf of an incompetent person without ___ evidence that the person would refuse the continuation of life sustaining treatment
clear and convincing
what is the primary or most important use of patient health info
patient care
dr harvey has changed a piece of datea in the patients record. the info that tracks this change and enables a jury to see this change in a med malpractice action is called
metadata
printing paper documents for an EHR system
creates legal challenges asto which document is the source of truth
and advance directive is used to direct individuals health care wishes in the event of
patient incapacitation
a late entry into the health record should
be identified as a late entry
record maintenance and content requiremenet are established in part by
NY state doh
TJC
CMS
the patient self determiniation act requires health care providers to
inform patients of their right to creat advance directives
document the presence or absence of advanced directives in the patient health record
abbreviations in the health record
should have only one meaning
what is most likely to happen to the health records of a physicians patient when a physician leaves an office practice
retained by the practice
mary is contemplating triple bypass surgery. informed consent by her surgeon would typically contain what elements
purpose of the proposed procedure
risks associated with the procedure
non invasive treatment alternatives
staff disagreements within the health record should be
avoided
mrs bolton is an angry patient who resents her dr "bossing her around". she refuses to take meds the nurse bring to her pursuant to drs orders and is verbally abusive to patient care assts. what is appropriate way to document her behavior in the record
noncompliant and hostile toward staff
emergencies are a exception to the consent requrement for
adults and minors
mrs davis is preparing to undergo hernia repair sugery . who should obtain the informed consent
the surgeon doing the surgery
changes to health record entries
are indicative of negligent care
legally, what is most important in determing the length of time that a hosp must retain records
statute of limitations
the uniform health care decision acts ranks next of kin for adults in what order for medical decision making
spouse, adult child, parent, adult sibling
johnyy is 12 and his parents are divorced. in order for johnny to receive medical treatment, who can consent
one parent must consent
a physician who performs a surgical procedure on a patient without obtaing consent may be liable for
battery
consent that is conveyed through spken or written words is
express
consent that is conveyed through a persons conduct is
implied
if an indiv is in an emergency condition and does not have capacity to communicate consent
consent is implied by law
a patient signs a consent form ,authorizing hsop staff to perform interventions necessary for overall medical care. this consent is
general
informed consent requires informing the patient of
nature and purpose of proposed treatment
risks and benefits of proposed treatment
alternatives to proposed treatment
if proposed med intervention is related to a research study
institutional review board approval is required
laws that require drivers to consent to blood alcohol tests, with penalties for refusal, probably exist to
protect the public
under the common rule, informed consent for human subjects in research studies may be waived if
the institutional review board approves a waiver
GINA applies to
health insurers
group health plans
employers with 15 or more employees
GINA
prohibits discrimination based on genetic info
under HIPAA, compound authorizations
combine informed consent with authorization for use and disclosure of a research subjects health info
advance directives
provide a way for physicians to ensure that life saving treatment is given, regardless of an indivuals wishes
if it is not durable, a POA is effective
only when the principle has capacity
a living will
expresses an indiv healthcare wishes when specific health conditions exist
a do not resuscitate order
is a type of advance directive
is used only in emergency situations
may be revoked at any time
the uniform anatomical gift act
promotes consistency among state laws
provides suggested standards for all aspects of organ donation
includes an opt in system for organ donation
when a competent adult refuses to consent to lifesaving treatment , the two competing sets of interest that come into play are the indiv privacy interest and
the governments interest in protecting and preserving human life
in re quinlan the court held that
an incompetent indiv has a right of privacy to terminate treatment
In the cruzan case, the missouri supreme court held that no one can make end of life choices on behalf of an incompetent person w/o
clear and convincing evidence
the endof life controversy in the terri schiavo case included
a question about teh authority of legislative bodies to intervene in judicial matters
the uniform health care decisions act
provides an additional option to creating advance directives
emancipated minors are defined as those who have
been afforded legal status as an adult
state laws most likely permit a monir to consent on their own behalf for
alcohol addiction
frances has been experience abdominal pain. removal of her gallbladder has been recommended. who is resp to obtain her informed consent
the physician who will perform the surger
the uniform photographic copies of business and public records as evidence act does what
allows record reproductions to be admited as evidence
the legal health record or designated record set is
designated record set is defined by HIPAA legislation
legal health recores is defined by the facility
legal health record my not include all of the info in the designated record set
destruciton of health records
may be a prudent business practice
the legal health record
is the record that is disclosed upon request
verbal orders by phone or in person are discouraged. in cases where verbal orders are necessary, what is the most effective method by which the risk of miscommunication can be lessened
person receiving order should read it back to insure the order is correct
integrity referes to
accuracy and completeness of info
authentication methods include
handwritten signature
rubber stamp signature
electronic signature
the integrity of EHR documentation is more susceptible that paper health record to what function
cut and paste
who has ultimate legal responsibility for the quality of care rendered in a healthcare org
governing body
what act served to make electronic transactions as enforeable as paper
uniform electronic transactions act
a countersignature
signifies review and evaluation of the first providers entry
an error in a paper health record should be
crossed out so that it can be seen but not relied on
a personal health record
may be housed in a system that a provider owns and controls
Law based upon judicial decision is called:
Common law
The collection of federal statutes is found in a:
Code
Which type of law involves the government as one of its parties?
Public Law and criminal law
A legislative act passed by Congress is an example of:
Statutory law
In general, if a South Carolina law and a North Carolina law conflict, whose law is follwed?
Each state follows its own law
Judicial decisions may be based on what type of actions?
a) disputes between individuals
b) challenges to the constitutionality of a statute
c) neither a nor b
d) both a & b
d) both a & b
If a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be follwed in determining this case is:
Stare decisis
What is the name of the intermediate court in the tiered structure of the state court system in nearly every state?
Appellate court
Appellate courts draft:
Opinions
In the United States, both the Federal and the State court systems use the _______-tier approach.
three
Statutory law derives from which branch of government?
Legislative
Regulations written by a state department of health or the U.S. Department of Health and Human Services are examples of:
Administrative law
"Which of the following occupies the highest hierarchal position?
a) Centers for Medicare and Medicaid Services
b) National Institutes of Health
c) Indian Health Service
d) United States Department of Health and Human Services"
d) United States Department of Health and Human Services"
The collection of federal statutory law is:
United States Code
Diversity jurisdiction refers to the ability to bring legal action in a:
Federal district court
Appellate courts are called _____ in the federal court system.
Circuit courts
"The standards of accrediting bodies such as The Joint Commission have the same legal authority as:
a) regulations issued by an administrative agency
b) s decision rendered by an appellate court
c) a statute enacted by a legislature
d) none of the above
d) none of the above
When a dispute is submitted to a disinterested third party and the third party settles the case, this is called:
Arbitration
A lawsuit has been filed by John Collins, a resident of VA, against a hospital in PA alleging the wrongful disclosure of a patients confidential information. This lawsuit could be filed in what type of court?
Federal district court
A legal matter was tried at the district court level and appealed to a federal appellate court. The case is now being appealed to the United States Supreme Court. Which statement is most correct
The U. S. Supreme Court will likely deny writ and decline this case for oral argument.
One or more advantages of arbitration over utilizing the court system to resolve a dispute is/are:
Time saving, cost saving, and increased privacy
Which laws are synonymous terms for court decisions?
Case law, common law, and judicial law
This type of law consists of rules and regulations issued by agencies that implement statutory law.
Administrative law
A principle of law that serves as a guide in similar subsequent cases is called:
Precedent
Alternate dispute resolution is an acceptable option to resolving cases via the court system for what type cases?
Civil and criminal cases
A jury does not
make determination of the law
An environmental service employee of the hospital is called to the vascular surgeon floor to clean the floor where a bag of Potassium chloride was spilled. After cleaning the floor, the employee failed to place any signs advising others of a wet floor. Mrs. Jones, a hospital employee fell on the floor and injured her back. She incurred medical expenses of $560.00 and loss wages in the amt of $1000.00. She brought suit and the jury awarded her $1560.00, representing reimbursement of the medical expenses and lost wages, plus $10k for the jurors; perceived recklessness on the part of the hospital. What is the $10k amt considered?
punitive damages
a defendant does not pay the damages awarded against her in a lawsuit. The court may order the seizure of a portion of her monthly wages to satisfy the judment in an action called
garnishment
a state appellete court will hear a case dealing with an injury to a patient if the atty appealing the case can prove
an error of law occurred
the following type of damages has been the primary target of the tort reform legislation
non economic compensatory damages
Mr. Green won a $500K lawsuit against Dr. Blue. Dr. Blue has appealed. Upon appeal, Mr. Green is referred to as
respondent
Dr. Robert is being sued for negligence by one of his patients. Dr. roberts decides to represent himself as his own atty. Dr Roberts is
acting pro se
When a patient discovers that a hemostat has been left in his abdomen by a surgeon, the patient must document and serve his allegations to the surgeon. The surgeon must respond via a legal document called:
answer
A plaintiff's attorney has filed a stat-law complaint in federal court. This is an error of what nature?
procedural law
Service of summons and complaint:
a) requires adequate notice to the defendent
b) may occur in person or via mail
c) both a and b
d) none of the above
c) both a and b
The Federal Rules of Civil Procedure apply to:
federal district courts
A health information management professional may attend legal proceedings and testify as to:
the authenticity of the patient's health record
Which of the following discovery methods is directed only towards parties involved in the litigation?
interrogatories
A deposition:
can be used to impeach a witness at trial
"The Federal Rules of Civil Procedure address:
a) trials
b) federal district court procedures
c) filing a lawsuit
d) all of the above
d) all of the above
When serves with a court order directing the release of health records, an individusl:
must comply with it
A subpoena duces tecum compels the recipient to:
bring records to a legal proceeding
A valid subpoena duces tecum seeking health records does NOT have to:
be signed by the plaintiff and defendant
Rule 23 of the Federal Rules of Civil Procedure specifically provides for what type of legal action?
class action
Information contained in a health record that is discoverable:
may or may not be admissable
A lawsuit has been filed against Lewisville Hospital for bodily injuries allegedly suffered by a patient during his inpatient hospital stay. Legal counsel for Lewisville Hospital believes the injuries reported in the plaintiff's complaint are exaggerated and the following discovery method is employed to determine the true extent of the injuries:
physical examination
The following step should NOT be included in a health information department's procedure for preparing health records in response to a subpoena:
remove pages containing detrimental information
Whether or not information may be introduced formally into evidence at trial is called:
admissibility
The medical record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wishes to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the:
business records exception
E-Discovery rules are amendments to the _________ and were created in response to the tremendous volume of evidence, maintained in electronic format, that is pertinent to lawsuits.
Federal rules of civil procedure
Per the theory of physician/patient privilege, the right to waive the confidentiality of medical information belongs to the
patient
Meta data is
information about an electronic record
A legal hold
is issued by a court if there is concern about destruction of information during litigation
Authentication of a record refers to
establishment of its baseline trustworthiness
A health record is representative of what type of evidence?
demonstrative evidence
The best evidence rule:
permits copies to be substituted in certain circumstances
Gloria Kramer files a medical malpractice lawsuit against Dr. Johnson, alleging that he committed negligence in the treatment of her diabetes. Ms. Kramer's attorney insists that Dr. Johnson cannot speak about of her medical diagnoses because of physician-patient privilege. Ms. Kramer's attorney:
is incorrect because she placed her medical condition at issue
From an evidentiary standpoint, incident reports
should not be placed in a patient's health record
During a trial to determine whether Dr. Smith was liable for medical malpractice, Dr. Smith testified in his own defense. Legally, Dr. Smith's testimony was:
direct evidence
Relevant evidence
tends to make the existence of a fact more or less probable
A hospital employee destroyed a health record so that its contents - which would be damaging to the employee - could not be used at trial. In legal terms, the employee's action constitutes:
spoilation
A health information management professional may attend legal proceedings and testify as to:
the authenticity of the patient's health record
Patient-provider privilege is defined by
state law
The medical record is admitted into evidence as an exception to what rule?
hearsay
The HIM professional may attend legal proceedings and testify as to which of the following?
the authenticity of the medical record
A subpoena duces tecum compels the recipient to do which of the following:
produce documents
A hospital employee destroyed a health record so that its contents, which would be damaging to the employee, could not be used at trial. In legal terms, the employee's action constitutes
spoliation
Which is issued by the court if there is concern that information may be destroyed in cases of current of potential litigation?
legal hold
A statement made to an attorney, psychologist or clergy that is protected from being revealed, even in court, is what type of communication?
privileged
"When determining whether or not evidence should be admissible in a court proceeding, the judge bases their decision by applying which of the following?
a) best evidence rule
b) hearsay exception
c) business records exception
d) all of the above
d) all of the above
When determining whether or not health records are privileged, the HIM professional should refer to which of the following?
state statutes
Which is not an area that describes a difference between electronic and paper records?
confidentiality
Which of the following employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed?
computer forensics
During a hearing to determine Worker's Compensation benefits for Tom Wilder, Mr. Wilder's medical records from Dr. Loop's office revealed that Mr. Wilder is HIV+. This information had been entered into Mr. Wilder's chart erroneously and was information about another patient. Mr. Wilder is not HIV+. Mr. Wilder filed a defamation lawsuit against Dr. Loop and his physician practice. What will be the most likely outcome?
No defamation liability because of the absolute privilege defense
The most likely successful cause of action resulting from intentional touching by a healthcare provider, without the patient's consent, is:
battery
Which elements must be present in order for damages in a negligence action to be awarded?
Injury, duty of care, breach of duty, causation
An environmental service employee of the hospital was called to the vascular surgery floor to clean the floor where a bag of KCI (potassium chloride) had spilled. After cleaning the floor, the employee failed to place any signs advising others of a wet floor. Mrs. Jones, a hospital visitor, fell on the wet floor and injured her back. She incurred medical expenses of $560 and lost wages in the amount of $1,000. She brought suit and the jury awarded her $1,560, representing reimbursement of the medical expenses and lost wages. What is this amount considered?
economic compensatory damages
What is the term used to denote a cause of action when a physician fails to perform with reasonable skill and care?
negligence
Assault and battery falls under the category of:
intentional tort
Johnny Doolittle died as a result of an adverse reaction to a medication administered during surgery at Getwell Hospital, a Joint Commission-accredited facility. The hospital had consistently failed to enforce Joint Commission standards requiring the presence of a complete history and physical exam on the patient's chart prior to surgery. Because of the absence of a history and phsycial exam on the patient's chart and the information it would have contained regarding drug allergies, the hospital may be found to have committed:
breach of duty
Conduct which places a person in reasonable apprehension of being touched in a manner that is insulting, provoking, or physically injurious is called:
assault
A patient is treated in the Emergency Room for severe laceration of the foot. The patient is given written instruction by the phsycian to have the sutures removed in three days, which the patient fails to do. A severe infection ensues resulting in permanent damage to the patient's foot. The patient sues the surgeon for negligence and the surgeon uses the ER record to prove what type of defense?
contributory negligence
The statue of limitations generally refers to:
period of time within which a lawsuit must be brought
All of the following must be proved to collect damages in a negligence suit except:
unlawful touching
What type of damages have been primary targets of tort reform legislation?
noneconomic compensatory damages
During hospitalization Mrs. Jones went into shock. Hot water bags and other restoratives were ordered by the attending physician. Because the temperature of the hot water bags was too high, and not checked by the nurse, Mrs. Jones suffered painful and permanent injuries. In this instance who may be sued under the doctrine of respondeat superior?
hospital
"What are the two types of causation necessary to meet the ""causation"" element of negligence?"
actual and proximate
A patient sued Dr. Smith for negligent care. Dr. Smith produced evidence showing that the patient's poor medical outcome was due to the patient's failure to follow his treatment plan and to take his prescribed medications. If a court refuses to grant the patient any money damages because the patient's action contributed to the harm what defense has the court applied to its final judgment?
contributory negligence
In the above situation if the court allows the plaintiff to only recover damages to the extent he/she was not responsible for the harm, what defense has the court applied to its final judgment?
comparative negligence
Which of the following terms denotes the suspension of the start of a statute of limitations clock?
tolling
Proximate cause is based on whether or not it was ____ that the defendant's breach of duty would cause the harm.
forseeable
Which of the following is not a valid defense to a claim of defamation?
information was spoken only; it was not in writing
A scalpel was left in a patient during an exploratory laparotomy. Additional surgery was required to remove the scalpel. Based on these facts, which one of the following rules applies?
res ipsa loquitur
The burden of proof usually falls upon the plaintiff, except in cases which apply the principle of:
res ipsa loquitur
What is the term used to denote the liability of an employer for the acts of its employees?
respondent superior
"Intentional confinement of an individual against his or her wishes may be legally defensible if:
a) a mentally ill patient is a danger to self and others
b) an individual has a dangerous contagious disease
c) both a and b
d) intentional confinement is never legally defensible
c) both a and b
If a hospital is held liable in its own right for the harm that the physicians on its medical staff cause to a patient, the legal theory being applied is:
respondeat superior
"Although a cause of action for false imprisionment may result if a hospital retains a patient against the patient's willis
a) is over 65
b) a danger to himself or others
c) has not paid his medical bill
d) has a highly contagious disease
b) a danger to himself or others
c) has not paid his medical bill
In general, the Uniform Photographic Copies of Business and Public Records as Evidence Act does which of the following?
allows record reproductions to be admitted as evidence
Which of the following statements about the "legal health record" or the "designated record set" is incorrect?
designated record set is defined by HIPAA legislation
Destruction of health records
may be a prudent business practice
The legal health record
is the record that is disclosed upon request
The legal health record must meet standards as defined by the following
federal regulations, state laws, accreditation body standards
Verbal orders by telephone or in person are discouraged. In cases where verbal orders are necessary, which of the following is the most effective method by which the risk of miscommunication can be lessened?
person receiving the order should read it back to insure order is correct
Which of the following exemplifies an acceptable patient record entry?
patient articulated pain level as a 6
Staff disagreements within the health record should be
avoided
Legally, which of the following is the most important in determining the length of time that a hospital must retain medical records?
statute of limitations
Integrity refers to the
accuracy and completeness of information
A goal of E-SIGN legislation was to
give electronic signatures in all business meetings
Auto-authentication
contradicts basic authentication standards
Authentication methods include:
handwritten signature, rubber signature stamp, electronic signature
Changes to health record entries
are acceptable in certain circumstances
A late entry into a health record should
be identified as a late entry
Abbreviations in the health record
should have only one meaning
The integrity of EHR documentation is more susceptible than the paper health record to which of the following functions?
cut and paste
Record maintenance and content requirements are established in part by
Department of Health and Human Services, Joint Commission, Centers for Medicare and Medicaid Services
What Act served to make electronic transactions as enforceable as paper transactions?
Uniform Electronic Transactions Act
A countersignature
signifies review and evaluation of the first provider's entry
An error in a paper health record should be
crossed out so that it can be seen but not relied on
A personal health record
may be housed in a system that a provider owns and controls
A physician who performs a surgical procedure on a patient without obtaining the patient's consent may be liable for
battery
Consent that is conveyed through spoken or written words is
express
Consent that is conveyed through a person's conduct is
implied
If an individual is in an emergency condition and does not have capacity to communicate consent
consent is implied by law
A patient signs a consent form, authorizing hospital staff to perform interventions necessary for overall medical care. This consent is
general
Informed consent requires informing the patient of all of the following except
hospital charges versus amount covered by insurance
Laws that require drivers to consent to blood alcohol tests with penalties for refusal, probably exist to
protect the public
Under the Common Rule, informed consent for human subjects in research studies may be waived if
the institutional review board approves a waiver
GINA applies to
health insurers, group health plans, employers with 15 or more employees
GINA
prohibits discrimination based on genetic information
Under HIPAA, compound authorizations
combine informed consent with authorization for use and disclosure of a research subject's health information
Advance directives
provide a way for individuals to communicate their healthcare wishes before they become incapacitated
If it is not durable, a power of attorney if effective
only when the principal has capacity
A living will
expresses an individuals healthcare wishes when specific health conditions exist
A do not resuscitate order
is a type of advance directive, is used only in emergency situations, may be revoked at any time
The Uniform Anatomical Gift Act
promotes consistency among state laws, provides suggested standards for all aspects of organ donation, includes an opt-in system for organ donation
When a competent adult refuses to consent to lifesaving treatment, the two competing sets of interest that come into play are the individual's privacy interest and
the governments interest in protecting and preserving human life
In In Re Quinlan, the court held that
an incompetent individual has a right of privacy to terminate treatment
In the Cruzan case, the Missouri Supreme Court held that no one can make end-of-life decisions on behalf of an incompetent person without
clear and convincing evidence
The Uniform Health-Care Decisions Act
provides an additional option to creating advance directives
Emancipated minors are defined as those who have
been afforded legal status as an adult
State laws most likely permit a minor to consent on their own behalf for which of the following conditions?
alcohol addiction
Frances has been experiencing abdominal pain. Removal of her gallbladder has been recommended. Who is responsible to obtain Frances' informed consent?
the physician who performed the surgery
What is an artificial being created per state statutory authority
corporation
What characterizes a corporation
it is separate from its owners or incorporators, it can sue or be sued, it can continue to exist despite an owner's death
Piercing the corporate veil refers to
holding corporation owners liable for bad acts
A non-for-profit corporation may
pay reasonable salaries to its employees
Bylaws
are the internal rules of an organization
A not-for-profit corporation that is formed for a charitable purpose
must meet IRS established criteria to be tax-exempt
Fiduciary duty includes
duty of loyalty and duty of responsibility
Ultra vires acts are those that
exceed a corporation's powers
General Hospital is a 1,000 bed facility. Mercy Hospital is a 100 bed hospital. They join to form one corporation which is named General Hospital. The restructuring that has most likely occurred is a
merger
Contracts
must contain an offer and acceptance
A physician has been found to have breached his contract with a patient through abandonment. As a remedy, the court may order
compensatory damages
A term used to describe standard contract terms is
warranty
In the "learned intermediary" defense used by HIT vendors, who is the learned intermediary
physician
Which of the following is not a federal antitrust law?
HIPAA
When two or more entities at different levels in a distribution chain act together to restrain trade, this is
vertical restraint of trade
Which offers both civil and criminal penalties?
Sherman Act
Which actions related to the medical staff might raise antitrust issues
excluding entire classes of practitioners from medical staff membership
Economic credentialing
may be associated with physicians who have an ownership in competing hospitals, may be based on perceived loss of loyalty by a physician, may be associated with a review of a physician's volume of cases
Noncompete agreements
might violate antitrust laws
Which of the following characterizes a join venture
created for a specific purpose and designed to have a limited lifespan
A publicly held corporation
generally has thousands of shareholders
Which of the following describes a responsibility of corporation's governing board members
appointing medical staff members
Which is not a required element for piercing the corporate veil?
corporation of a not-for-profit entity
Challenges to tax-exempt corporations operating with charitable purpose include
aggressive billing practices, insufficient charity care provided, inflated billing practices toward the uninsured
What is an artificial being created per state statutory authority
corporation
What characterizes a corporation
it is separate from its owners or incorporators, it can sue or be sued, it can continue to exist despite an owner's death
Piercing the corporate veil refers to
holding corporation owners liable for bad acts
A non-for-profit corporation may
pay reasonable salaries to its employees
Bylaws
are the internal rules of an organization
A not-for-profit corporation that is formed for a charitable purpose
must meet IRS established criteria to be tax-exempt
Fiduciary duty includes
duty of loyalty and duty of responsibility
Ultra vires acts are those that
exceed a corporation's powers
General Hospital is a 1,000 bed facility. Mercy Hospital is a 100 bed hospital. They join to form one corporation which is named General Hospital. The restructuring that has most likely occurred is a
merger
Contracts
must contain an offer and acceptance
A physician has been found to have breached his contract with a patient through abandonment. As a remedy, the court may order
compensatory damages
A term used to describe standard contract terms is
warranty
In the "learned intermediary" defense used by HIT vendors, who is the learned intermediary
physician
Which of the following is not a federal antitrust law?
HIPAA
When two or more entities at different levels in a distribution chain act together to restrain trade, this is
vertical restraint of trade
Which offers both civil and criminal penalties?
Sherman Act
Which actions related to the medical staff might raise antitrust issues
excluding entire classes of practitioners from medical staff membership
Economic credentialing
may be associated with physicians who have an ownership in competing hospitals, may be based on perceived loss of loyalty by a physician, may be associated with a review of a physician's volume of cases
Noncompete agreements
might violate antitrust laws
Which of the following characterizes a join venture
created for a specific purpose and designed to have a limited lifespan
A publicly held corporation
generally has thousands of shareholders
Which of the following describes a responsibility of corporation's governing board members
appointing medical staff members
Which is not a required element for piercing the corporate veil?
corporation of a not-for-profit entity
Challenges to tax-exempt corporations operating with charitable purpose include
aggressive billing practices, insufficient charity care provided, inflated billing practices toward the uninsured
Discovery method that includes written questions that must be answered by potential witness
interrogatories
state appellate court will hear a case dealing with an injury to a patient if the attorney appealing the case can prove
an error of law occurred
when served with a court order directing the release of health records, an individual
must comply with it
defendent fails to respond to a plaintiffs complaint, this may result in
default judgment
following step should NOT be in health info dept procedure for preparing records in response to a subpoena
remove pages containing detrimental info
from an evidentiary standpoint, incident reports
should not be placed in the patients health record
medical record of kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wishes to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the
business records exception
E-discovery rules are amendments to the _____ and were created in response to the tremendous volume of evidence, maintained in electronic format that is pertinent to lawsuits
federal rules of civil procedure
Relevant eveidence
tends to make the existance of a fact more or less probable
authentication of the record refers to
establishment of its trustworthiness
environmental service employee of the hosp was called to the vascular surgery floor to clean the floor where a bag of potassium chloride spilled. after cleaning the floor, the employee failed to place a sign about a wet floor. mrs jones, a hosp visitor fell on the floor and got hurt. she incurred med expense of $560. and lost wages of $1000. she brought suit and the jury awarded her $1560, representing reimbursement of the med expenses and lost wages, plus $10k for jurors perceived recklessness on the part of the hosp. what is the $10k considered?
punitive damages
HIM professional may attend leagal proceedings and testify as to
authenticity of patients health record
hosp employee destroyed a health record so that its contents-which would be damaging to the employee- could not be used at trial. In legal terms the employees action constitutes
spoliation
plaintiffs attorney has filed a state-law complaint in fed court. this is an error of what nature?
procedural law
gloria kramer files a med malpractice lawsuit against dr johnson alleging that he committed negligence in the treatment of her diabetes. ms. kramers attorney insists that dr johnson can't speak about her med diagnosis becuase of physician-patient privilege. ms. kramers attorney
is incorrect because she placed her med condition at issue
per the theory of physician/patient privilege, the right to waive the confidentiality of med info belongs to the
patient
metadata is
info about an electronic record
patient-privilege is defined by
state law
subpoena duces tecum compels the recipient to
bring records to a legal proceeding
defendant does not pay the damages awarded against her in a lawsuit. the court may order the seizure of a portion of her monthly wages to satisfy the judgment in an action called
garnishment
if a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be followed in determining the case is
stare decisis
collection of fed statutes is found in a
code
concept of confidentiality applies to
all data and info systems
automated paper and verbal communications
clinical, financial and business records
what is the intermediate court in the tiered structure of the state court system in nearly every state?
appellate court
appellate courts are called ________ in federal court system
circuit courts
regulations written by the state dept of health of US dept of health and human svcs are examples of
administrative law
what law(s) involve govt as one of the parties?
public law and criminal law
principle of law that serves as a guide in similar subsequent cases is called
precedent
when a dispute is submitted to disinterested 3rd party and the 3rd party settles the case, this is
arbitration
In the US, both the federal and state court systems us a _____ tier approach
three
judicial decision may be based on the following types of actions
disputes between individuals
challenges to the constitutionality of a statute
legislative act passed by congress is an example of
statutory law
what is the legal term used to define the protection of health info in the patient-provider relationship
confidentiality
law based on judicial decision is called
common law
mary has gone to her dr to discuss a med condition, what legal term best describes the type of communication that has occured between them
priviledged communication
health info privacy has been established in all but one way
constitutional right
custodian of health records refers to the individual within an organization is responsible for what action
authorized to certify records
supervise the inspection and copying of record
testifies to the authenticity of records
term used to describe a patient has the right to maintain control over certain personal info is referred to as
privacy
what is the term used to physical and electronic protection of health information
security
what is also known as case law
judicial law
party that presents evidence to disprove or disprove wrongdoing is the
defendant
criminal law is a type of
public law
US code is
statutory law
under the concept of stare decisis
lower courts look to higher courts
fed court has legal control over cases involving federal statutes. this legal contol is referred to as
jurisdiction
this legal doctrine limits excessive litigation by prohibiting subsequent lawsuits about the same matter and involving the same parties once a decision has been made and all appeals have been exhausted
res judicata
one restriction involving diversity jurisdiction is
no plaintiff can be from the same state as any of the defendants
what court is the lowest court in the tiered structure of the state court system in nearly every state
trial court
legislative act passed by congress is an example of
statutory law
centers for disease control and prevention is located in the US
dept of health & human services
federal court system, appellate courts are called
circuit courts
legal matter was tried at the district court level and appealed to a fed appellate court. the case was appealed to the US supreme court, which declined to hear it. when the supreme court declined the case it
denied cert
med malpractice appeal brought by carol agains mercy hosp has just concluded. the court reached a decision in favor of the hosp. the courts written determination that outlined the facts of the case and the legal theories followed to reach its outcome is an
opinion
federal trial courts are called
district courts
lawsuit is brought against a govt in
court of claims
appellate courts hear appeals on final judgments of
trial court decisions
US congress follows the model
bicameral
agency that is heavily involved in combating medicare & medicaid fraud is
inspector general for health & human services
in general, if virginia and texas laws conflict
each state follows its own law
one or more advantages of mediation over utilizing the court system to resolve a dispute are
time saving
cost saving
increase privacy
deeming authority has been granted by the US dept of HHS to the
american osteopathic assoc
authority of TJC is mostequivalent to that of the
commission of accreditation of rehab facilities
health information privacy protection has been established in court decisions, federal laws, state laws, but not
constitutional rights
who owns the health record
provider who generated the info
what is the term used most often to describe the indiv within an org who is responsible for protecting health info in conjuction with the court system
custodian of record
many laws address patient privacy and confidentially. what other resourses address the providers resp for keeping health info private
professional code of ethics
when someone is identified as an information steward, the indiv is resp for what activities
integrity of electronic health record
protecting loss or destruction of electroinic health record
security of record
courts rules that guide a lawsuit from beginging to end is
procedural law
class action lawsuits often involve
groups of consumers against large entities
legal proceedings that accompany a lawsuit is
litigation
dr huffman has been sued by a patient, he brings in the manufacturer as defendant. this process is
joinder
service is
notification of a lawsuit
process that allows evidence to be used in a court of law and considered by a jury is
admissibility
mary has been deposed via a subpoena duces tecum. as the HIM director of hosp, she will bring the health record of a patient. her role is
authenticate the records validity
court orders for the production of records
do not require patient authorization
subpoena
may be issued by a partys attorney
forma, written objections to subpeonas are often made in a
motion to quash
when removing a health record in response to a subpoena duce tecum or a court order, what should be completed
an index of contents
bench trial refers to a trial
without a jury
excusal of a juror without a stated reason is
peremptory challenge
the burdon of proof in which a plaintiff must prove that it was more likely than not that each element of a case was met is
compensatory damages
actual damages, which compensate a plaintiff for losses incurred are
compensatory
what type of damage is collected by implementing monetary caps to couteract lavish jury awards
non-economic compensatory
party who appeals a trial court decision is
appellant
if a plaintiff incurs $30k in damages realted to a medical expense and lost wages, what are these
economic compensatory damages
mrs black sued mr brown for failing to return the clock. mr brown ignured mrs blacks lawsuit and she won a judgment of $1000. the court encumbered mr browns property so that when he tried to sell it 3 years later, he was unable to take any profit from the sale until mrs black was first pait this is
judgment lien
when mr brown ignored mrs blacks lawsuit she won the case under what legal theory
default judgment
dr howard is called to testify in a med malpractice case against dr hale. he testifies that base on his expertise of the subject matter. dr dale didnt commit med malpractice. dr howard is a/an
expert witness
when an indiv represents herself as her own attorney she is
acting pro se
when a patient discovers that a sponge has been left in his abdomen, the patient brings a lawsuit. to do this the patient must document and serve his allegations to the surgeon in a legal document called
complaint
lawsuit has been filed against a hosp for bodily injuries allegedly suffered by a patient. legal counsel for the hosp believes the injuries are exaggerated. he used what discovery method to determine the true extent of the injuries
physical exam
whether or not information may be introduced formally into evidence at trial is called
admissibility
per the theory of physician/patient privilege, the right to waive the confidentiality of medical info belongs to the
patient
metadata is
info about electronic record
legal hold
is issued by a court if there is concern about destruction of info during litigation
authenticiation of a record refers to
establishment of its baseline trustworthiness
health record is representative of what type of evidence
demonstrative evidence
best evidence rule
permits copies to be substituted in certain cercumstances
from an evidentiary standpoint, incident reports
should not be placed in a patients health record
during a trial to determiine wheither dr smith was liable for medical malpractice, dr smith testified in his own defense. legally, dr smiths testimony was
direct evidence
relevant evidence
tends to make theexistence of a fact more or less probable
patient-provider privelege is defined by
state law
medical record is admitted into evidence as an exception to what rule
hearsay
HIM professional may attend legal proceedings and testify to
authenticate the health record
subpoena duces tecum compels the recipient to NOT do;
serve on a jury
answer a complaint
produce documents
what is issued by the court if there is concern that info may be destroyed iin cases of current or potential litigation
legal hold
statement made to an attorney, psychologist or clergy that is protected from being revealed even in court is what type of communication
privileged
when determining whether or not evidence should be admissible in a court proceeding, the judge bases his discision on
best evidence rule
hearsay exception
business records exception
when determining whether or not health records are privileged, the HIM professional should refer to
state statutes
what is not a difference between electronic and paper records
confidentiality
what employs scientific methods to analyze sources of electronic data to determine if evidence was accessed or destroyed
computer forensics
during hospitalization, mrs jones went into shock. hot water bags and other restoratives were ordered by attending physician. because the temp of water bags was too high, and not checked by the nurse, mrs jones suffered painful and permanent injuries. in this instance who may be sued under the doctrine of respondent superior
hospital
what type of damages have been primary targets of tort reform legislation
non-economic compensatory damages
what is the term to denote a cause of action when a physician fails to perform with reasonable skill and care
negligence
if the court allows the plaintiff to only recover damgages to the extent (percentage) he was responsible for harm, what defense has the court applied to its final judgment
comparative negligence
scalpal was left in a ptient during an exploratory aparotomy. additional surgery was required to remove the scalpel. based on the facts, what rule applies
res ipse loquitur
unlawful intusion on an individual is considered
invasion of privacy
burden of proof usually falls upon the plaintiff, except in case which apply the principle of
res ipsa loquitur
what term denotes the suspension of the start of the statute of limitations clock
tolling
the most likely cause of action from intentional touching by a healthcare provider, without patients consent is
battery
conduct which places a person in reasonable apprehension of being touched in a manner that is insulting , provoking or physically injurious is
assault
patient sued for negligent care. dr smith produced evidence showing that the patients poor medical outcome was due to the patients failure to follow his treatment plan and take the meds. if a court refuses to grant the patient any money damages because the patients actions contributed to the harm, what defense has the court applied to its final judgment
contributory negligence
statute of limitations generally refers to
period of time within which a lawsuit must be brought
patient is treated in er for laceration of the foot. the patient is given written instructions by the dr to have the sutures out in 3 days which the patient fails to do. an infection ensues resulting in permanent damage to the foot. the patient sues the surgeon for negligence and the surgeon uses the er record to prove what type of defense
contibutory negiligence
what is a valid defense to a claim of defamation
info was not published to a third party
info was spoken only , it was not in writing
communication was privileged because it was an issue of public safety
assault and battery fall under the category of
intentional tort
what elements must be present in order for damages in a negligence action be awarded
injury, duty to care, breach of duty, causation
proximate cause is based on whether or not it was ___ that the defendants breach of duty ould cause harm
forseeable
johnny died as a result of an adverse reaction to meds given during surgery at mercy hosp, a joint commission accredited facility. the hosp had consistently failed to enforce TJC stancdards requiring the presence of a complete history and physical exam on the patients chart prior to surgery. because of the absence of a history and physical exam on the patients chart and the info it would have contained regarding drug allergies, the hosp may be found to have committed
breach of duty
during a hearing to determint workers comp benefits for tom, his med records from dr loop revealed that tom is HIV+. this info had been entered into toms chart erroneously and was informormation about another patient. Tom is not HIV+. Tom filed a defamation lawsuit against dr loop and his physician practice. what will be the most likey outcome
no defamatiion on liability because of the absolute privlege defense
most likely successful cause of action resulting from intentional touching by a healthcare provider w/o patients consent is
batter
which elements must be present in order for damages in a negligence action to be awarded
injury, duty of care, breach of duty, causation
assault and battery falls under the category of
intentional tort
what type of damages have been primary targets of tort reform legislation
noneconomic compensatory damages
what are the 2 types of causation necesary to meet the causation element of negligence
actual and proximate
if a court allows the plaintiff to only recover damages to the extent he was not responsible for the harm, what defense has the court applied to its final judgement
comparative negligence
intentional confinement of an individual against his wishes may be legally defensible if
a mentally ill patient is a danger to self and others
an indiv has a dangerous contagious disease
although a couse of action for false impreonment may result if a hosp retains a patient against their will, a hosp may be protected from liability if the patient
is a danger to himself or others
has a highly contagious disease
hosp is held liable in its own right for the harm that the physicians on its medical staff couase to a patient, the legal theory being applied is
respondeat superior
what is an artificial being created per state statutory authority
corporation
what characterizes a corporation
it is separate from its owners or incorporators
it can sue or be sued
it can continue to exist despite an owners death
piercing the corporate veil refers to
holding corporation owners liable for bad acts
not for profit corp may
pay reasonable salaries to its employees
bylaws
are the internal rules of an organization
not for profit corp that is formed for a charitable purpose
must meet irs established criteria to be tax exempt
fiduciarty duty includes
duty of loyalty
duty of responsibility
ultra vires acts are those that
exceed a corporations powers
general hosp is a 1000 bed facility. mercy hosp is a 100 bed facility. they join to form one corp, which is named general hosp. the restructuring that has most likely occured is a
acquisition
contracts
must contain an offer and acceptance
physician has been found to have breached his contract with a patient through abandonment. as a remedy, the court may order the following
compensatory damages
term used to describe standard contract terms is
boilerplate
learned intermediary defense used by HIT vendors, who is the learned intermediary
physician
what is not a federal antitrust law
HIPPA
What are federal antitrust laws
sherman act
clayton act
federal trade commission act
when two or more entities at different levels in a distribution chain act together to restrain trade, this is
vertical restraint of trade
what act offers both civil and criminal penalties
sherman act
what actions related to the medical staff might raise antitrust issues
excluding entire class of practitioners from medical staff membership
economic credentialing
may be associated with physicians who have an ownership in competing hospitals
may be based on a perceived loss of loyalty by a physician
may be associated with a review of a physicans volume of cases
noncompete agreements
might violate antitrust law
what is NOT a defense for nonperformance of a contract
specific performance
what is a defense for nonperformance of a contract
fraud
mistake of fact
duress
what characterizes a joint venture
created for a specific purpose
designed to have a limited lifespan
publicly held corp
generally has thousands of shareholders
what describes a responsibility of corps governing board members
appointing medical staff members
what is NOT a required element for piercing the corporate veil
corp is a not for profit entity
what is a required element for pierceing the corporate veil
complete domination of the corp by its owners
control by owners was used to perpetrate a wrongful act
corp control was the proximate cause of injury
challenges to tax exempt corps operating with a charitable purpose inclue
aggressive billing practices
insufficient charity care provided
inflated billing practices toward the uninsured
legal health record must meet requirements as defined by
federal regulations
state laws
accreditation body standards
once the paper has been converted to microfild or scanned into electronic record, the info cannot be used as evidence
false
gold of E-sign legislation was to
give electronic signatures increased legal standing
mary is 95, while an inpatient at general hosp she agrees she doesnt want to be resuscitated if she would have a cardiac arrest. she signs a form and the physician documents it in the record this is
DNR order
janice arrives at her physicians office for her appt and pays her office visit co-pay. her dr examines her. based on these facts janices consent is
implied
auto-authentication
contradicts basic authentication standards
cruzan case, the court held that a person cannot assume end of life decisions on behalf of an incompetent person without ___ evidence that the person would refuse the continuation of life sustaining treatment
clear and convincing
what is the primary or most important use of patient health info
patient care
dr harvey has changed a piece of datea in the patients record. the info that tracks this change and enables a jury to see this change in a med malpractice action is called
metadata
printing paper documents for an EHR system
creates legal challenges asto which document is the source of truth
advance directive is used to direct individuals health care wishes in the event of
patient incapacitation
late entry into the health record should
be identified as a late entry
record maintenance and content requiremenet are established in part by
NY state doh
TJC
CMS
patient self determiniation act requires health care providers to
inform patients of their right to creat advance directives
document the presence or absence of advanced directives in the patient health record
abbreviations in the health record
should have only one meaning
what is most likely to happen to the health records of a physicians patient when a physician leaves an office practice
retained by the practice
mary is contemplating triple bypass surgery. informed consent by her surgeon would typically contain what elements
purpose of the proposed procedure
risks associated with the procedure
non invasive treatment alternatives
staff disagreements within the health record should be
avoided
mrs bolton is an angry patient who resents her dr "bossing her around". she refuses to take meds the nurse bring to her pursuant to drs orders and is verbally abusive to patient care assts. what is appropriate way to document her behavior in the record
noncompliant and hostile toward staff
emergencies are a exception to the consent requrement for
adults and minors
mrs davis is preparing to undergo hernia repair sugery . who should obtain the informed consent
the surgeon doing the surgery
changes to health record entries
are indicative of negligent care
legally, what is most important in determing the length of time that a hosp must retain records
statute of limitations
uniform health care decision acts ranks next of kin for adults in what order for medical decision making
spouse, adult child, parent, adult sibling
Johnny is 12 and his parents are divorced. in order for johnny to receive medical treatment, who can consent
one parent must consent
physician who performs a surgical procedure on a patient without obtaing consent may be liable for
battery
consent that is conveyed through spken or written words is
express
consent that is conveyed through a persons conduct is
implied
indiv is in an emergency condition and does not have capacity to communicate consent
consent is implied by law
patient signs a consent form ,authorizing hsop staff to perform interventions necessary for overall medical care. this consent is
general
informed consent requires informing the patient of
nature and purpose of proposed treatment
risks and benefits of proposed treatment
alternatives to proposed treatment
proposed med intervention is related to a research study
institutional review board approval is required
laws that require drivers to consent to blood alcohol tests, with penalties for refusal, probably exist to
protect the public
under the common rule, informed consent for human subjects in research studies may be waived if
the institutional review board approves a waiver
GINA applies to
health insurers
group health plans
employers with 15 or more employees
GINA
prohibits discrimination based on genetic info
under HIPAA, compound authorizations
combine informed consent with authorization for use and disclosure of a research subjects health info
advance directives
provide a way for physicians to ensure that life saving treatment is given, regardless of an indivuals wishes
if it is not durable, a POA is effective
only when the principle has capacity
living will
expresses an indiv healthcare wishes when specific health conditions exist
do not resuscitate order
is a type of advance directive
is used only in emergency situations
may be revoked at any time
uniform anatomical gift act
promotes consistency among state laws
provides suggested standards for all aspects of organ donation
includes an opt in system for organ donation
when a competent adult refuses to consent to lifesaving treatment , the two competing sets of interest that come into play are the indiv privacy interest and
the governments interest in protecting and preserving human life
re quinlan the court held that
an incompetent indiv has a right of privacy to terminate treatment
cruzan case, the missouri supreme court held that no one can make end of life choices on behalf of an incompetent person w/o
clear and convincing evidence
end of life controversy in the terri schiavo case included
a question about teh authority of legislative bodies to intervene in judicial matters
uniform health care decisions act
provides an additional option to creating advance directives
emancipated minors are defined as those who have
been afforded legal status as an adult
state laws most likely permit a monir to consent on their own behalf for
alcohol addiction
frances has been experience abdominal pain. removal of her gallbladder has been recommended. who is resp to obtain her informed consent
the physician who will perform the surger
uniform photographic copies of business and public records as evidence act does what
allows record reproductions to be admited as evidence
legal health record or designated record set is
designated record set is defined by HIPAA legislation
legal health recores is defined by the facility
legal health record my not include all of the info in the designated record set
destruciton of health records
may be a prudent business practice
legal health record
is the record that is disclosed upon request
verbal orders by phone or in person are discouraged. in cases where verbal orders are necessary, what is the most effective method by which the risk of miscommunication can be lessened
person receiving order should read it back to insure the order is correct
integrity referes to
accuracy and completeness of info
authentication methods include
handwritten signature
rubber stamp signature
electronic signature
integrity of EHR documentation is more susceptible that paper health record to what function
cut and paste
who has ultimate legal responsibility for the quality of care rendered in a healthcare org
governing body
what act served to make electronic transactions as enforeable as paper
uniform electronic transactions act
countersignature
signifies review and evaluation of the first providers entry
error in a paper health record should be
crossed out so that it can be seen but not relied on
personal health record
may be housed in a system that a provider owns and controls
Name three ways that the Health information privacy protection has been established.
Court decisions, State laws, Federal laws
Mary Smith has gone to her doctor to discuss her current medical condition, what is the legal term that best describes the type of communication that has occurred between Mary and her physician?
Privileged communication
The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as:
Privacy
What is the legal term used to define the protection of health information in a patient-provider relationship?
Confidentiality
What is the legal term used to describe the physical and electronic protection of health information?
Secrity
The "custodian of health records" refers to the individual within an organization who is responsible for:
Authorized to certify records, supervise inspections and copying of records, and testifies to authenticity of records
Who owns the health record?
Provider who generated the information
What is the term used most often to describe the individual within an organization who is responsible for protecting health information in conjunction with the court system?
Custodian of Record
If a healthcare provider is accused of breaching the privacy and confidentiality of a patient what resource may a patient rely on to substantiate the providers responsibility for keeping health information private?
Professional Code of Ethics
The concept of confidentiality applies to:
All data and information systems, automated, paper, and verbal communications, clinical, financial, and business records
Law based upon judicial decision is called:
Common law
The collection of federal statutes is found in a:
Code
Which type of law involves the government as one of its parties?
Public and criminal
A legislative act passed by Congress is an example of:
Statutory and administrative law
In general, if a South Carolina law and a North Carolina law conflict, whose law is follwed?
Each state follows its own law
Judicial decisions may be based on what type of actions"
Disputes between individuals and challenges to the contitutionality of a statute
If a lawsuit with the same fact pattern as a previous case is brought to the same court, the legal principle most likely to be follwed in determining this case is:
Stare decisis
What is the name of the intermediate court in the tiered structure of the state court system in nearly every state?
Appellate court
Appellate courts draft:
Opinions
In the United States, both the Federal and the State court systems use the _______-tier approach.
three
Statutory law derives from which branch of government?
Legislative
Regulations written by a state department of health or the U.S. Department of Health and Human Services are examples of:
Administrative law
Of the following,CMS, NIH, IHS, and HHS, which occupies the highest hierarchial position?
HHS
The collection of federal statutory law is:
United States Code
Diversity jurisdiction refers to the ability to bring legal action in a:
Federal district court
Appellate courts are called _____ in the federal court system.
Circuit courts
When a dispute is submitted to a disinterested third party and the third party settles the case, this is called:
Arbitration
A lawsuit has been filed by John Collins, a resident of VA, against a hospital in PA alleging the wrongful disclosure of a patients confidential information. This lawsuit could be filed in what type of court?
Federal district court
One or more advantages of arbitration over utilizing the court system to resolve a dispute is/are:
Time saving, cost saving, and increased privacy
Which laws are synonymous terms for court decisions?
Case law, common law, and judicial law
This type of law consists of rules and regulations issued by agencies that implement statutory law.
Administrative law
A principle of law that serves as a guide in similar subsequent cases is called:
Precedent
Alternate dispute resolution is an acceptable option to resolving cases via the court system for what type cases?
Civial and criminal cases
Confidentiality
a legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure
Custodian of health records
the person designated as responsible for the operational functions of the development and maintenance of the health record and who may certify through affidavit or testimony the normal business practices used to create and maintain the record
Electronic health record (EHR)
a computerized record of health information and associated processes; an electronic record of health-related information on an individual that conforms to nationally recognized standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
Hybrid health record
a record that uses a combination of paper and electronic formats
Legal health record (LHR)
the form of health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization's legal health record depending on how the organization defines it
Ownership
in healthcare, the person to whom the health record belongs (traditionally, the healthcare provider)
Personal health record (PHR)
an electronic or paper health record maintained and updated by an individual for himself or herself
Privacy
the quality or state of being hidden from, or undisturbed by, the observation or activities of other people or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information
Security
1. The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss; 2. The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems
Administrative law
rules and regulations created by administrative agencies
Arbitration
a form of alternative dispute resolution in which a dispute is submitted to a third party or panel of experts outside the judicial trial system
Case law
the body of law that is created when, as the result of a dispute, a court renders a decision
Civil law
noncriminal law
Common law
the body of law (that is, judicial or case law) that is created when a court renders a decision as the result of a dispute
Conflict of laws
an inconsistency between the laws of different states arising from a legal action that involves the territory of more than one jurisdiction
Criminal law
a type of law in which the government is a party prosecuting an accused who has been charged with violation a criminal statute or regulation
Due process of law
the guarantee provided under the Constitution and the Bill of Rights that laws will be reasonable and not arbitrary and allow for challenges to a law's content and substance
Executive branch
the branch of government charged with enforcing laws, including the issuance of regulations by administrative agencies, with ultimate executive-branch power vested in the chief executive (the president of the United States on the federal level and the governor of each state at the state level)
Judicial law
the body of law created as a result of court (judicial) decisions
Legislative branch
the branch of government charged with enacting laws in the form of statutes through the Senate and House of Representatives
Mediation
a form of alternative dispute resolution in which a dispute is submitted to a third party and the outcome is decided by agreement of the parties
Private law
the branch of law concerned with the rules and principles that define rights and duties among people and among private businesses
Public law (PubL)
the branch of law concerned with the federal, state, or local government and its relationship to individuals and business organizations; the most familiar form of public law is criminal law
Separation of powers
among the three branches of federal and state governments, the authority of each is limited in order to inhibit the ability of any one branch of government to become autocratic
Stare decisis
Latin for "let the decision stand"; a legal doctrine stating that local courts within a court system are bound to follow (apply) the decisions of higher courts in the same court system in order to determine the outcome of a case, as long as the fact pattern of the case in the higher court is similar to that of the current case
Statutory law
law based on statutes, which are created by the legislative branch of the government (the House of Representatives and the Senate)
Admissibility
Evidence that is allowed to be admitted in a court of law
Burden of Proof
The task of sufficiently proving or establishing the requisite degree of belief for each element of a case; usually belongs to a plaintiff
Compensatory Damages
Damages in which the plaintiff is compensated for losses incurred; actual damages
Complaint
The document that is filed with a court in order to commence a lawsuit
Court order
A document issued by a judge that compels certain actions, such as testimony or the production of documents such as health records
Defendant
The individual or organization that is the object of the lawsuit, and against whom a lawsuit is brought; wrongdoer
Discoverability
Limitations on the ability of parties to discover pretrial information held by another party
Interrogatories
Discovery devices consisting of written questions given to a party, witness, or other person who has information needed in a legal case
Jury
The fact-finding body that hears evidence given by the parties, if they testify, and other witnesses; observes presented by both sides; hears the opening statements and closing arguments of each side; and decides facts based on the perceived credibility of the evidence, but does not decide law
Lay witness
An individual's testifying based on his or her own observations of the situation(s) that prompted the case at hand
Plaintiff
The individual who initiates a lawsuit to enforce either his or her rights or another's obligations
Procedural law
The court's rules that guide a lawsuit from the time it begins through completion, whether it culminates in a trial or ends with a settlement or dismissal
Respondent
The party against whom a petition is filed on appeal
Trial
The stage in a lawsuit after the pretrial phase if the parties do not negotiate a settlement and the case is not dismissed
Voir dire
The process through which a jury is selected
Admissibility
evidence that is allowed to be admitted in a court of law
Authenticated evidence
evidence that appears to be relevant and has been shown to have a baseline authenticity or trustworthiness
Circumstantial evidence
evidence that is not directly from an eyewitness or participant and requires some reasoning to prove a fact
Demonstrative evidence
actual objects, pictures, models, and other devices that are supposedly intended to clarify the facts for the judge and jury
Direct evidence
"real, tangible or clear evidence of a fact, happening or thing that requires no thinking or consideration to prove its existence" (ALM Media Properties 2012)
Discoverability
limitations on the ability of parties to discover pretrial information held by another party
e-Discovery
pretrial legal process used to describe the methods by which parties will obtain and vie electronically stored information
Hearsay
a written or oral statement made outside of court that is offered in court as evidence
Legal hold
a court order that suspends the processing or destruction of paper or electronic records; also known as a preservation order, preservation notice, or litigation hold.
Spoliation
intentional destruction, mutilation, alteration, or concealment of information relevant to a legal proceeding
Compensatory damages
damages in which the plaintiff is compensated for losses incurred; actual damages
Contributory negligence
an individual's conduct contributed in part to the injury that the individual suffered
Corporate negligence
a doctrine under which hospitals may be held liable in their own right
Damages
monetary compensation awarded by a court to an individual injured in a civil action through the wrongful act of another party
Intentional torts
torts that involve a deliberate or intentional act
Joint and several liability
a principle that allows each defendant in a legal action to be held responsible for the entire amount of damages that a plaintiff is awarded, regardless of the defendant's degree of fault
Misfeasance
relating to negligence or improper performance during an otherwise correct act
Noneconomic damages
damages that are not monetary in nature; an issue targeted by tort reforms
Punitive damages
damages that exceed compensatory damages and serve to punish the defendant(s)
Res ipsa loquitur
Latin for "the thing that speaks for itself"; an exception to the plaintiff having the burden of proof in which the facts or circumstances accompanying an injury may raise a presumption, or at least permit an interference, of negligence on the part of the defendant or some other individual who is charged with negligence and the burden of proof is shifted to the defendant
Respondeat superior
Latin for "let the master answer"; the doctrine under which a hospital holds itself responsible for the actions of its employees provided those individuals were acting within the scope of their employment or at the hospital's direction at the time of the activity in question.
Tort
a civil wrong for which the law provides a remedy in the form of a lawsuit to recover damages
Tort law
law that involves the right of an individual, corporation, or other legal entity to recover damages for a loss caused by the defendant (tortfeasor or wrongdoer)
Tort reform
the variety of measures intended by legislatures to overhaul the justice system; with regard to medical malpractice, such reforms are intended to diminish the number of lawsuits and large jury verdicts, stabilize the market, and ultimately reduce premiums for physicians
advance directive
a legal document that specifies an individual's healthcare wishes in the event that he or she has a temp. or permanent loss of competence
consent
a patient's acknowledgement that he or she understands a proposed intervention, including that intervention's risks; benefits, and alternatives. 2. a patient's agreement that protected health information can be disclosed; the document that provides a record of the patient's consent.
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
express consent
consent that is communicated through words, regardless of whether those words are written or spoken
general consent
a form that covers routine diagnostic procedures and medical treatment by a hospital staff as well as other activites such as release of info for treatment purposes and disposal of human tissue and body fluids
good samaritan law
state law or statute that protects healthcare providers from liablity for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident
implied consent
consent for medical treatment that is communicated through a person's conduct or some other means besides words
informed consent
a type of consent in which the patient should have a basic understanding of which medical procedures or tests may be performed as well
living will
a document executed by a competent adult that express that individual's wishes to limit treatment measures when specific health related diagnoses or conditions exist
power of attorney (POA)
a legal instrument used by a principal (person) to grant legal authority to one or more agents to make certain legal and financial decisions on behalf of the principal
therapeutic priviledge
a doctrine that has historically allowed physicians to withhold information information from patients in limited circumstances..
uniform heatlh care decisions 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 suggest decision making priority for that individual's surrogates.
authentication
verification of records validation therefore it is reliable and truthfulness as evidence;also a security mechanism to validate the identity of a user in an electronic format
authenticity
the genuineness of a record, that is what it purports to be; information is authentic if proved to be immune from tamperng and corruption
completeness
an element of a legally defensible record; the health record is not complete until all parts are assembled and the appropriate documents are authenticated according to medical staff bylaws
designated record set (DRS)
a group of records maintained by or for a covered entity encompassing medical records and billing records about individuals and enrollment, payment, claims adjudication, and case or medcial management record systems maintained by or for a health plan used, in whole or in part , by or for the covered entity to make decisions about individuals
legal health record (LHR)
the form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organizations legal health record varies depending on how the organization defines it
master patient index (MPI)
a patient identifying directory that serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death
retention
a mechanism for storing records, providing for timely retrieval, and establishing the length of time that various types of records will be retained by the healthcare organization
statutes of limitations
a statutory enactment that places time limits on certain items
uniform electronic transactions Act
federal statute that makes electronic transactions as enforceable as paper transactions, removing barriers to electronic commerce and increasing trust associated with electronioc business transactions
affiliated covered entities
legally separate covered entities, affliated by common ownership or control; for purpose of the Privacy Rule, these legally separate entities may refer to themselves as a single covered entity
covered entities
persons or organizations that must comply ith the HIPPA Privacy and security rules; include healthcare providers, health plans, and healthcare clearinghouses
deidentified information
information from which personal characteristics have been stripped and that, as a result, neither identifies or nor provides a reasonable basis to believe it could identify an individual.
health information technology for economic and clinical health act (HITECH)
federal legislation that was passed as a portion of the Amercan Recovery and Reinvestment act; contains changes to the HIPAA Privacy rule
notice of practices
A statement issued by a healthcare organization that informs individuals of the uses and disclosures of patient's identifiable health information that may be made by the organization, as well as the individual's rights and the organization's legal duties with respect to that information
privacy act of 1974
a law that requires federal agencies to safeguard personally identifiable records and provides individuals wth certain privacy rights
protected health information
a term defined n the HIPPA privacy Rule as "individual identfiable health information that is transmitted by electronic media, maintained in electronic medium, or transmtted or maintained in any other form or medium
encryption
a technique used to ensure that data transferred from on location on a network to another are secure from eavesdropping or interception
security officer or chief security officer
an individual responsible for overseeing privacy policies and procedures
technical safeguards
security measures that are based on technology rather than on adminstration or physical security, including access control, unique user identification, automatic logoff, and encryption and decryption
business record
a record that is made and kept in the usual course of business, at or near of the event recorded
Uniform Photographic Copies of Business Act
Act allowing record reproductions to be admitted as evidence
Legal Health Record
Health record that is released upon request
Repeat Back
Most effective method of insuring information given over the phone is accurate.
Statute of Limitations
The legal, most important factor in determing the length of time that a hospital must retain medical records.
Integrity
refers to the accuracy and completeness of information
E-Sign
legislation giving electronic signatures increased legal standing
auto-authentication
type of authentication contradicting basic authentication standards
authentication
hand-written signature, rubber stamp signature and electronic signature.
Uniform Electronic Transactions Act
Act served to make electronic transactions as enforceable as paper transactions.
PHR
may be housed in a system that a provider owns and controls
countersignature
signifies review and evaluation of the first provider's entry
Late entry
Documentation to the legal record that is allowable and should be specifically noted to the time of entry to the record
medical staff
Those with the ultimate responsiblility for the quality of care rendered in healthcare organization
evidence is
means by which the facts are proved or disproved
p.54
discoverability
limitations on the ability of parties to discover pretrial information held by another p.55
metadata
data about data
p.57
legal hold
issued by the court if there is concern that information may be destroyed. suspends processing or destruction of paper or electronic records p.63
spoliation
intentional destruction,mutilation, alteration, or concealment of evidence p.63
admissibility
evidence that is allowed to be admitted in a court of law, acquired legally and relevant p.66
if evidence appears relevant
it must be authenticated
p.67
physician - patient privilege
encourages patients to fully disclose all relevant information
p.72
peer review
physicians reviewing physicians
p.76
DRS Designated Record Set
group of records maintained by or for a covered entity
p.525
statutes of limitations
two years from time known about
p.526
correcting errors in documentation
written in ink will be the word 'error', the time and date, and initial p.527
authentication
doctor is the author and agrees to its contents
p.528
hearsay
did not actually hear. Medical record exempt from hearsay
p.528
best evidence rule
prevents fraud or mistakes to the contents of a document or record p.528
protected health care
primary aim of HIPAA privacy rule
p.529
privacy act of 1974
set the stage for HIPAA. grants rights to find out about information collected, to see and copy info., to correct and amend info., and control disclosure of information p.530
emancipated minor
take parents rights away
p.538
power of attorney
authority to act and make decisions on behalf of another party
p.538
elements of negligence or malpractice
Duty, Breach, Proximate cause, and Harm or damages
p.544
reasonable man standard
evaluate in light of own general experience
p.544
res ipsa loquitur
the thing speaks for itself
p.544
informed consent
information about anticipated treatment and its risks and alternatives p.545
law
rules designed to protect citizens living in a civilized society
p.2
two types of law
public and private
p.2
health information
primary use is for clinical care
p.2
him and informatics professionals
individuals responsible for protecting the privacy and security of health information p.2
health information refers to
data generated and collected as a result of delivering care to a patient p.3
health record comprised of
information generated on a patients episode of care
p.3
hybrid health record
consists of paper and electronic records
p.3
EHR or EMR
complete electronic health record
p.3
EHR
created and managed across more than one healthcare organization p.3
EMR
created and managed within one healthcare organization
p.3
HIPAA
Health Insurance Portability and Accountability Act of 1996
p.4
HITECH
Health Information Technology for Economic and Clinical Health Act p.4
privacy
to be left alone
p.5
ASTM
American Society for Testing and Materials. Now known as ASTM International (in class)
confidentiality
sensitive data that needs to be protected from theft, disclosure, or improper use, only authorized individuals or organizations with a need to know p,5
privileged communication
what records of communication are privileged based on providers practice p.5
security
restricting access
(in class)
data security
effective data protection measures
p.6
system security
totality of safeguards
p.6
information security
provides integrity, confidentiality, and availability
p.6
ownership
provider who generated the record, person who created
p.7
custodian of health records
responsible for the operational functions related to the development and maintenance of records p.7
steward or stewardship
responsible for ensuring integrity
p.8
code of ethics
morally binding
(in class)
four ethical principles
Autonomy-make ones own decision Benefience-doing good Nonmalefience-doing no harm Justice-whats right for all p.8
public law
involves the federal, state and local government. Both civil and criminal law p.18
private law
involves private busimesses. Only civil law
p.18
administrative law
rules and regulations created by administrative agencies
p.19
statutes
enacted by a legislative body
CFR Code of Federal Regulations
annual editions, what was passed into law
(in class)
stare decisis
lower courts must look to higher courts
persuasive authority
one court looks to another for guidance
p.22
jurisdiction
territory of legal control, legal authority
p.22
three parts of government
Executive branch-carries out Legislative branch-creates laws Judicial branch- judge everything p.22-24
HHS
Health and Human Services
p.22
separation of power
provides check and balance between the three branches of government- executive, legislative and judicial
p.25
state court system is three tier
trial courts, limited jurisdiction, and general jurisdiction
p.25
federal court system is three tier
trial courts(district), appellate(circuit) and supreme court
p.26
diversity jurisdiction
enables parties from different states to engage in a lawsuit in federal court p.28
arbitration
makes decisions
(in class)
mediation
mutual decision
(in class)
procedural law
the courts rules that guide a lawsuit
p.32
most legal healthcare cases are
civil rather than criminal
p.32
parties in a lawsuit
plaintiff and defendant
p.32
litigation
legal proceedings that accompany a lawsuit
p.33
pro se plaintiff
represents himself during litigation
p.33
counter claim
claim by a defendant against a plaintiff
p.33
joinder
defendant brings in a outsider as a codefendant
p.33
discoverability
limits on parties to discover pretrial information held by another
p.34
deposition
oral testimonies of individuals are obtained
p.34
subpoena
appointed time and place to testify under oath. issued by the clerk of court or an attorney
p.34
interrogatories
written discovery, question and answer document
(in class)
three types of discovery
deposition, interrogatories, and production of documents
p.34-5
e-discovery
key evidence contained in e-mails
p.35
mental examination
considered the fourth type of discovery
p.36
subpoena duces tecum
instructs the recipient to appear and produce documents and other records p.37
elements of valid subpoena
name of court, plaintiff and defendants names, case docket number, date, time, place to appear with information commanded,name of issuing attorney p.38
motion to quash
written objections to subpoenas
p.38
preparation of documents for a subpoena duces tecum
9 steps. remove material that is not requested in the subpoena
p.40
health records are evidence in
civil and criminal cases
p.41
two types of compensatory damages
Economic-medical expenses Noneconomic-pain and suffering
p.46
punitive damages
punishment for the defendant
p.46
nominal damages
awarded to recognize wrongdoing
p.46
qui tam
whistle blower
(in class)
stare decisis
let the decision stand
p.519 abdelhak
respondeat superior
let the master answer
p.522 abdelhak
intentional tort claims include
assault, battery, false imprisionment, defamation of character, invasion of privacy, and fraud p.522 abdelhak
assault
words of threat
p.522 abdelhak
battery
touching without consent
p.522 abdelhak
defamation of character
oral-slander written- libel
p.523
four sources of law
Constitutions, Statutes, Administrative Law, Common Law
law is divided into two types they are
public and private
legislative process is
enacting laws in the form of statutes-they are creating laws
congress is made up of
the senate and the house of representatives
express consent
clearly communicated through words, whether written or spoken p.138
implied consent
consent for medical treatment that is communicated through a persons conduct not words p.138
express written informed consent
providers should use for risky, alternative or invasive interventions p.138 -39
informed consent
have all the facts, basic understanding of medical procedures
p.139
AMA suggests physicians should disclose and discuss with patients
the diagnosis, nature and purpose of treatment, risks and benefits of treatment, alternatives regardless of cost, risk and benefits of alternatives, risks and benefits of not receiving treatment. These are all opportunities for patient to ask questions p.139
The Joint Commission requires that
an executed informed consent be placed in the patient's health record prior to surgery, unless not possible because of an emergency p.139
IRB
Institutional Review Board. They deal with research and approve it. p.140
in clinical trials you consent to
participate and allow access to your records
(in class)
providers who fail to properly obtain informed consent prior to performing a medical intervention run the risk of liability for
battery or negligence
p.141
Good Samaritan statute
protects varies healthcare providers from liability for not obtaining a informed consent before rendering care at an accident or emergency, without compensation p.142
non compos mentis
not of sound mind
p.143
waiver
ability of a patient to waive the right to informed consent
p.143
the informed consent requirement for human subjects research may be waived or altered if approved by the institutional review board (IRB). To approve must have these elements:
research involves no more than minimal risk to subjects, the waiver will not adversely affect the rights and welfare of the subject, research could not practicably be carried out without the waiver, subject will be provided with pertinent information after participation p.143
an IRB may waive the informed consent requirement when a research study involves a
retrospective review of charts
p.143
therapeutic privilege
has been applied in extreme situations in which a provider believes that the risk of physical or psychological injury to the patient resulting from full disclosure outweighs the patients right to be fully informed p.144
GINA
Genetic Information Nondiscrimination Act
GINA prohibits
health insurance and employment discrimination based on genetic information p.144
advance directives
means for individuals to communicate their healthcare wishes in advance should they become incapacitated. Includes living will and who has decision making power p.145 and in class
living wills
individuals wishes to limit treatment measures when specific conditions exist and the individual cannot communicate on their own p.146
DNR
Do Not Resuscitate, should not perform CPR. Can be revoked by patient not family p.147
DNI
Do Not Intibate- not to go on machine
(in class)
Patient Self Determination Act (PSDA)
requires healthcare institutes that bill Medicare and Medicaid for services to provide adult patients with information about the various types of advanced directives p.148
Uniform Anatomical Gift Act
created an opt-in system for organ donation where individuals are not considered to be organ donors unless they have specifically indicated a desire to donate p.149
right to die court decisions have ruled
competent adults right to refuse consent to medical treatment applies even when the treatment is life saving p.151
when the refusal to consent is based on religious belief
the First Amendment's freedom of religion clause provides additional authority for refusing treatment p.151
In the matter of Robert Quackenbush case
the hospitals main argument was that the patient was committing suicide by refusing treatment. He was found mentally competent p.152
incompetent adults
an individual is no longer competent due to an illness or an injury p.153
emancipated minors
those who have been afforded legal status as an adult
p.156
separated and divorced parents of a minor
healthcare providers may first seek consent from the custodial parent. However state law should be followed regarding relative rights p.157
Duncan v.Scottsdale Medical Imaging
plaintiff alleged that she informed defendants that she was allergic to certain medications and specifically stated that she only consented to the injection of morphine or demerol p.159
whether consent is written or oral
it should be documented in the individuals health record
p.160
short form
orally presented must be a witness. states elements of informed consent
(in class)
long form
no witnesses needed. includes all of the informed consent requirements p.161
tort
civil wrong for which the law will provide a remedy in the form of a lawsuit to recover damages, a wrong causing damage p.86
damages
monetary compensation awarded by a court to an individual who has been injured p.86
liability
legal obligation or responsibility (amount owed)
p.86
civil law
government does not get involved with, awards monetary compensation
p.86
criminal law
government prosecutes accused
p.86
felony
more serious in nature than a misdemeanor
p.86
misdemeanor
less severe crime than a felony
p.86
jurisdiction
legal authority an entity possesses to make a legal decision
p.87
examples of intentional torts
battery, assault, false imprisonment, infliction of emotional distress. Meant to do it. p.87
battery
physical contact without permission
p.87
assault
causes apprehension, no actual contact is necessary
p.88
false imprisonment
intentional confinement of a person, use of restraints
p.88
infliction of emotional distress
key element is that it has caused additional distress
p.88
emotional distress
sleeplessness, anxiety, irritability, inability to perform activities as before p.89
negligence
failure to act responsibly
p.89
medical malpractice
alleged wrongful act committed by a healthcare provider against a patient p.89
standard act of care
what an individual is expected to do or not in a particular situation p.89
two types of negligence
malpractice and criminal negligence
p.90
criminal negligence
reckless disregard for another individuals safety
p.90
nonfeasance
failure to perform an act. Didn't do it
p.90
misfeasance
improper performance of an act. Made a mistake
p.90
malfeasance
intended to cause damage. Intentional
p.90
four elements of negligence
duty, breach, approximate cause, and injury
p.91
two types of compensatory damages
non-economic and economic
p.91
punitive damages
damages that exceed compensatory damages and serve to punish the defendant p.91
res ipsa loquitur
LIQUOR, the thing speaks for itself
p.92
contributory negligence
bars a plaintiff from recovering damages from the defendant if defendant can prove plaintiff's conduct contributed to injury suffered p.93
comparative negligence
plaintiffs recovery to be reduced by some amount based on his or her percentage of negligence p.93
act of god
out of human control
p.95
charitable immunity
shields hospitals and other institutions from liability for negligence p.95 and 495
corporate negligence
going after corporation, protects the individuals
p.95
respondeat superior
let the master answer
p.96
defamation
false communication causing harm to a persons reputation
p.99
slander is
oral defamation
p.99
libel is
written defamation
p.99
3 elements of invasion of privacy
duty to not invade, breach of that duty, damages from breach
p.99
3 elements of breach of confidentiality (fiduciary duty)
duty to not disclose health information, breach of that duty, damages p.100
statutes of limitations
limited time after problem exists
p.103
tolled
postponed, suspended, extended
p.104
partnership
two or more people agree to work together and share the risks and rewards
p.120
sole proprietorship
single owner
p.120
corporation
protects owner from personal liability for debts
p.121
not for profit corporation
can make money, not for personal use for corporation purposes
p.122
bylaws
internal rules of an organization, board of directors design
p.123
fiduciary duty
duty of loyalty and a duty of responsibility
p.123
duty of loyalty
board members put the interest of the corporation ahead of their personal interests p.123
duty of responsibility
act with do care in exercising duties
p.123
due diligence
exercise a legally acceptable level of care
p.123
a contract is
legally enforceable oral or written agreement
p.125
for a contract to be legal it must contain
a description of the agreement, offer, acceptance, and consideration p.125
offer
a valid promise by one party to do or not do something if the other party agrees to do or not do p.125
acceptance
meeting of the minds on terms that are sufficiently definite and complete p.125
consideration
what each party will receive from the other in return for performing the obligations described in the contract
defenses for nonperformance of a contract
fraud, mistake of fact, duress, illegality, and impossibility
fraud
doing something wrong for personal gain
(in class) p.126
mistake of fact
parties relied on information
(in class) p.126
duress
stressed into
(in class) p.126
illegality
element in contract
(in class) p.126
impossibility
acts impossible to perform
(in class) p.126
exculpatory contracts
clauses that seek to excuse a party in advance from any potential liability - "cedar point" p.126
compensatory damages
attempt to return to the injured party money it would have had
p.126
arbitration
may be binding or nonbinding on the parties, in other words it makes the arbitrators decision advisory in nature p.127
hold harmless/indemnification clauses
to either transfer or assume liability
p.127
warranties
they will fix the problem
(in class)
learned intermediary
when they learn something wrong, they have to let you know
(in class)
physician-patient relationship
letting physician know you want to enter into a contract
(in class)
antitrust law
be able to trust, to protect interest, restraint of trade
(in class) not all restraints of trade are actual antitrust violations
p.130
noncompete agreement
individual agrees not to compete directly or work for a competitor for a certain period p.133
examples of tort reform for malpractice actions include all of the following except one:
NOT affidavit of merit
If a patient claims negligence as the result of misuse of a laser during mole removal, the following records would probably be admissible:
NOT All medical records from the physician doing the mole removal
the Uniform photographic copies of business and public records as evidence act (UPA):
NOT allows the admissibility of reproductions into evidence in all legal cases.
Which of the following is incorrect? A late entry in the health record:
NOT shall be documented as a late entry.
Which of the following types of records may be protected from discovery by privilege?
NOT medical records
If an individual consents to treatment, but later alleges that she was not fully informed of the risks, benefits, and alternatives, what legal claim is most appropriate?
NOT misfeasance
Physicians:
NOT are only obligated to treat patients with whom a written contract has been signed.
what term refers to the strategic management of enterprise electronic information including standards, policies, and procedures for access, use, and control of that information?
information governance
if parties to a contract agree to hold each other harmless for each other's actions or inactions
indemnification
the following types of damages has been the primary target of tort reform legislation
non-economic compensatory damages
To which of the following does GINA apply?
health insurers
which of the following is/are required for a legal contract to be formed?
all of the above
which type of defamation of character occurs when a false communication is made in writing about an individual?
libel
service of a summons and complaint:
both a and b
which of the following would constitute a violation of the federal trade commission act?
offering misleading prices
the electronic discovery reference model (EDRM):
was developed to assist in the e-discovery process