Chapter 1 Introduction to the American Legal System
- The Nature of Law
- Sources of Law
- Governmental Organization and Function
- Organization of the Court System
Chapter 2 Medical Records and Managed Care
- Utilization Review
- Managed Care
- Managed Care Organizations and Related Entities
- The Impact of Managed Care on Health Information
- Management
- HIPAA and State Privacy Rules
- Changes in Medical Records Standards
Chapter 3 Medical Records Requirements
- Records That Must Be Kept
- The Legal Health Record
- Content Requirements
- Record Retention Requirements
- Destruction of the Record
Chapter 4 Medical Records Entries
- Legible and Complete Medical Records Entries
- Timely Medical Records Entries
- Authorship and Countersignatures
- Authentication of Records
- Verbal Orders
- Corrections and Alterations
Chapter 5 Document Consent to Treatment
- Legal Theories of Consent
- Distinguishing Informed Consent and HIPAA Authorization
- Who Can Give Consent
- Responsibility for Obtaining Consent
- Documentation
- Types of Consent Forms
Chapter 6 Access to Health Information
- Types of Health Information
- Ownership of the Medical Record
- Summary of Confidentiality Requirements
- HIPAA Covered Entities
- Exercise of Professional Judgment
- Minimum Necessary Rule
- Hybrid Entities, Affiliated Covered Entities, and Organized Healthcare Arrangements
- Uses and Disclosures of Medical Records Information
- Record Duplication and Fees
- QIO Record Keeping
- Business Associates
- Additional Patient Rights Under HIPAA
- Verifying Identity and Representations
- HIPAA Administrative Requirements
Chapter 7 Reporting and Disclosure Requirements
- Disclosures Required by Law
- Other Health Related Reporting Requirements
Chapter 8 Documentation and Disclosure: Special Areas of Concern
Chapter 9 HIV/AIDS: Mandatory Reporting and Confidentiality
- Duty to Report
- Protecting Confidentiality of HIV-Related Information
- Statutory Provisions Regarding Disclosure
- Liability for Unauthorized Disclosure of HIV-Related Information
- Recommended Policies and Procedures
Chapter 10 Discovery and Admissibility of Medical Records
- Discoverability of Medical Records
- Admissibility of Medical Records
- Other Healthcare Documentation
Chapter 11 Legal Theories in Improper Disclosure Cases
- HIPAA Liability
- Other Statutory Bases for Liability
- Theories of Liability
Chapter 12 Risk Management and Quality Management
- Increased Scrutiny of Medical Errors and Demand for
- Improving Quality Care
- Relationship Between Risk Management and Quality Management
- Risk Management
- Quality Management
- HIPAA and Risk Management/Quality Management
- Compliance Programs
- Medical Records in Risk Management,Quality Review, Compliance Activities, and Pay for Performance Initiatives
Chapter 13 Electronic Health Records
- The Movement to Electronic Health Records
- HIPAA Privacy Rule
- HIPAA Security Rule
- State Data Security Laws
- Regulatory Issues
- Electronic Health Records as Evidence
- Professional Liability
- Specific Electronic Health Records Security Issues
Chapter 14 Health Information in Medical Research
- U.S. Federal Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
- State Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
- International Laws Relating to Medical Records and Clinical Trials
- Other Guidance
- Conclusion
Appendix A Glossary: Acronyms and Definitions
Index
