228 terms

HIM FOL Final Exam

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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?
Security
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
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
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
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
A jury does not
make determination of the law
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
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 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
Mr. Green owon a 500K lawsuit against Dr. Blue. Dr. Blue has appealed. Upon appeal, Mr. Green is referred to as
respondent
mr. Green owon a 500K lawsuit against Dr. Blue. Dr. Blue has appealed. Upon appeal, Dr. Blue is referred to as
petitioner
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
the best evidence rule
permits copies to be substituted in certain circumstances
the following type of damages has been the primary target of the tor reform legislation
non economic compensatory damages
Gloria Kramer files a medical malpractive lawsuit against Dr. Johnson, alleging that he is committed negligence in the treatment of her diabetes. Ms. Kramer's atty insists that Dr. Johnson cannot speak about any of her medical diagnoses because of patient physician priveldge. ms. Kramer's atty
is incorrect because she placed her medical condition at issue
From the evidentiary standpoint, indicent reports
should not be placed in the patient's medical record
During a trial to deteremine 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 exixtense of a fact more or less probable
a hospital employee destroyed medical records so that it contents- which would be damaging to the employee- could not be used at a trial. In legal terms, the employee's action constitutes
spoiliation
Patient- provider priviledge is defined by
state law
Describe all the players in a lawsuit
judge- decision maker
plaintiff and defendent
- parties in lawsuit
jury-
group of people that decide verdict
benchtrial-
decision made without a jury trial, judge decides
bailiff-
keeps order in the court
court reporter-
records the communication
attorney-
knows and speaks the law on behalf of plaintiff or defendent
Explain the differenfce between discoverablity and admissibility
discoverability is evidence that cant be necessarily used in a trial
admissibility-
evidence that can be used in a trial, the judge feels it is acceptable
Distinguish differences between noneconmonic compensatory damages and punitive damages
noneconomic compensatory damages do not have a monetary value
punitive damages
go above and beyond the damages, it is there to punish the defendent for their wrong doing
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
Although HIPAA is not the first piece of federal privacy legislation, it is more expansive than the Privacy Act of 1974, which applied privacy rules
Federal agencies
The HIPAA privacy rule
is federal common law
St. Joseph's Hospital has a psychiactric service on the sixth floor of the hospital. A 31 yr old male has come inot the HIM dept. and requested to see a copy of his medical record. He has told your clerk he was a patient of Dr. Schmidt, a psychiatrist, ans was on the sixth floor of St. Joseph's for th last two mths, These records are not psychotherapy notes. The best course of action for you to take , as the HIM director, is
allow the patient to access his record if, after contacting the physician, his physician doesnt feel that it is harmful to the patient
Medical information loses PHI status and is no longer protected by the HIPAA privacy rule
is de identified
Linda Wallace is being admitted to the hospital. She is presented with a "Notice of Privacy Practices" In the Notice, it is explained to her that PHI will be used and disclosed for treatment, paymt, and operations (TPO) puposes. Linda states that she doesnt want her PHI used for that purpose
the hospital is not required to honor her wishes in this situation, as the notice of privacy practices is info only and the hospital must try to get written acknowledgement from Linda that she was presented with a copy of the notice of privacy practices
Today, Janet Kim, visited her new dentist for an appt. She was not presented with a notice of privacy practices. Is this acceptable?
no, it is a violation of the HIPAA privacy rule
The HIPAA privacy rule
both a nd b or incorrect. it doesn't apply to meidicare patients and doesnt only apply to govt operated healthcare facilities
The HiPAA recognized consent is a patient's agreement to
use or disclosure for TPO purposes
An original goal of HIPAA Administrative Simplification was to standardize
the electronic transmission of health data
The Kids' Foundation, a foundation related to Children's Hospital. Is mailing fundraising info to the familes of all patients who have been treated at Children's hospital in the last three years. Based on the facts given
children hospital must have notified the patients/ patients' guardians of this disclosure in the notice of privacy practices
Champion Hospital retains Hall, Hall and Hall, a law firm, to perform all of its legal work, including representation during medical malpractice lawsuits. Which of the follwing statements are correct?
the law firm is a business assoc. because it performs activities on behalf of the hospital and it uses or discloses individually identifiable information
You are a member of the hospital's health information management committee. The committee has created a HIPPA complaint Authorization Form. Which of the following items does the Privacy rules not require
signature of the patient's attending physician
Which of the following is not an element that makes info "PHI" under the HIPAA Privacy rule
contained within the personnel file
One of the medical staff committees at st vincent hospital is responsible for reviewing cases of patients readmitted within 14 days after discharge. This review of patients' medical records is
treatment
Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a
business associate
Lane hospital has a contract with Ready Clean, a local company, to come into the hospital to pick up all of the facility's linens for offsite laundering ready clean is
not a business associate because it doesnt use or disclose individually identifiable information
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is
protected by the privacy rule beaucese it is individiually identifiable
The designated health record set
includes medical and billing records
The HIPAA Security rules is one of the two main parts of the Health Ins. Portability of 1996. T/F
True
Public Interest and benefit uses and disclosures under the privacy rule
sometimes requires the patient's agreement or authorization
One of the medical staff committees at st vincent hospital is responsible for reviewing cases of patients readmitted within 14 days after discharge. One of the four general requirements a CE must adhere to in order to be in compliance with the HIPAA security rule includes the following
ensure the confidentiality, integrity and availablity of the ePHI
What is the primary distinctinos between the HIPAA Security Rule and the HIPAA Privacy Rule"?
both a and b the privacy rule applies ot all forms of patient's PHI, whether electronic, written, or oral. in contract, the Security rule covers only PHI that is in electronic format. and the security rule provides far more comprehensive security requirements than the privacy rule and includes a level of detail not provided in the privacy rule
The HIPAA Security Rules applies to which of the following covered entities?
All of the above: hospital that bills medicare, physician electronic billing company, blue cross health insurance plan
Addressable implementation specifications in the Security Rules standards are optional: therefore, the CE does not have to show that the standard has been met. T/F
False
The HIPAA Security Awareness and Training administrative safeguards requires all fo the following addressable implementation programs but one for an entity's workforce
disaster recovery plan
Which of the following statements is false about the Security Officer?
security officer is a required full time position under HIPAA security rule
Noncompliance with the HIPAA Security Rule can lead to
neither A nor B. it can not lead to civil penalties up to $25,000 per person per yr or Criminal penalties up to $250,000 and 10 yrs in prison
The director of the Health Information Services is allowed access to the medical record tracking system when providing the proper log in and password. Under what access security mechanism is the director allowed access to the system?
user based
An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?
role based
Although HIPAA is not the first piece of federal privacy legislation, it is more expansive than the Privacy Act of 1974, which applied privacy rules
Federal agencies
The HIPAA privacy rule
is federal common law
St. Joseph's Hospital has a psychiactric service on the sixth floor of the hospital. A 31 yr old male has come inot the HIM dept. and requested to see a copy of his medical record. He has told your clerk he was a patient of Dr. Schmidt, a psychiatrist, ans was on the sixth floor of St. Joseph's for th last two mths, These records are not psychotherapy notes. The best course of action for you to take , as the HIM director, is
allow the patient to access his record if, after contacting the physician, his physician doesnt feel that it is harmful to the patient
Medical information loses PHI status and is no longer protected by the HIPAA privacy rule
is de identified
Linda Wallace is being admitted to the hospital. She is presented with a "Notice of Privacy Practices" In the Notice, it is explained to her that PHI will be used and disclosed for treatment, paymt, and operations (TPO) puposes. Linda states that she doesnt want her PHI used for that purpose
the hospital is not required to honor her wishes in this situation, as the notice of privacy practices is info only and the hospital must try to get written acknowledgement from Linda that she was presented with a copy of the notice of privacy practices
Today, Janet Kim, visited her new dentist for an appt. She was not presented with a notice of privacy practices. Is this acceptable?
no, it is a violation of the HIPAA privacy rule
The HIPAA privacy rule
both a nd b or incorrect. it doesn't apply to meidicare patients and doesnt only apply to govt operated healthcare facilities
The HiPAA recognized consent is a patient's agreement to
use or disclosure for TPO purposes
An original goal of HIPAA Administrative Simplification was to standardize
the electronic transmission of health data
The Kids' Foundation, a foundation related to Children's Hospital. Is mailing fundraising info to the familes of all patients who have been treated at Children's hospital in the last three years. Based on the facts given
children hospital must have notified the patients/ patients' guardians of this disclosure in the notice of privacy practices
Champion Hospital retains Hall, Hall and Hall, a law firm, to perform all of its legal work, including representation during medical malpractice lawsuits. Which of the follwing statements are correct?
the law firm is a business assoc. because it performs activities on behalf of the hospital and it uses or discloses individually identifiable information
You are a member of the hospital's health information management committee. The committee has created a HIPPA complaint Authorization Form. Which of the following items does the Privacy rules not require
signature of the patient's attending physician
Which of the following is not an element that makes info "PHI" under the HIPAA Privacy rule
contained within the personnel file
One of the medical staff committees at st vincent hospital is responsible for reviewing cases of patients readmitted within 14 days after discharge. This review of patients' medical records is
treatment
Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a
business associate
Lane hospital has a contract with Ready Clean, a local company, to come into the hospital to pick up all of the facility's linens for offsite laundering ready clean is
not a business associate because it doesnt use or disclose individually identifiable information
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is
protected by the privacy rule beaucese it is individiually identifiable
The designated health record set
includes medical and billing records
The HIPAA Security rules is one of the two main parts of the Health Ins. Portability of 1996. T/F
True
Public Interest and benefit uses and disclosures under the privacy rule
sometimes requires the patient's agreement or authorization
One of the medical staff committees at st vincent hospital is responsible for reviewing cases of patients readmitted within 14 days after discharge. One of the four general requirements a CE must adhere to in order to be in compliance with the HIPAA security rule includes the following
ensure the confidentiality, integrity and availablity of the ePHI
What is the primary distinctinos between the HIPAA Security Rule and the HIPAA Privacy Rule"?
both a and b the privacy rule applies ot all forms of patient's PHI, whether electronic, written, or oral. in contract, the Security rule covers only PHI that is in electronic format. and the security rule provides far more comprehensive security requirements than the privacy rule and includes a level of detail not provided in the privacy rule
The HIPAA Security Rules applies to which of the following covered entities?
All of the above: hospital that bills medicare, physician electronic billing company, blue cross health insurance plan
Addressable implementation specifications in the Security Rules standards are optional: therefore, the CE does not have to show that the standard has been met. T/F
False
The HIPAA Security Awareness and Training administrative safeguards requires all fo the following addressable implementation programs but one for an entity's workforce
disaster recovery plan
Which of the following statements is false about the Security Officer?
security officer is a required full time position under HIPAA security rule
Noncompliance with the HIPAA Security Rule can lead to
neither A nor B. it can not lead to civil penalties up to $25,000 per person per yr or Criminal penalties up to $250,000 and 10 yrs in prison
The director of the Health Information Services is allowed access to the medical record tracking system when providing the proper log in and password. Under what access security mechanism is the director allowed access to the system?
user based
An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?
role based
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 mmune 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