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Medical Charting and Documentation, Part 3: Legal Aspects of Documentation (1 credit hours)
This module discusses important legal aspects of documentation including negligence, malpractice and corporate responsibility. Health care information privacy, confidentiality, and legal ramification of disclosure are described as well as the impact of HIPAA.

Planners, content specialists and feedback personnel have declared that there is no conflict of interest in the preparation and content of this module. There is no commercial support for or endorsement of products in this module.

Katherine Ott, MSW, ELS
Katherine Ott, M.S.W., ELS, is a managing editor for the American Society of Radiologic Technologists and a certified Editor in the Life Sciences. She has written and edited several articles on medical imaging and radiation therapy for various ASRT publications.
Barbara Wallace, RHIA, CCS, CCS-P
Contributing Author
Barbara Wallace is an associate professor of Health Information Management at Sinclair Community College (Dayton, OH). She has over 12 years experience as an HIM educator and 14 years experience as a department director and vice president in the healthcare industry.
After studying the information presented, the reader should be able to:
  • Recognize the legal implications of medical record documentation with respect to negligence, malpractice and corporate responsibility.
  • Describe the legal obligations of health care professionals with regards to confidentiality and privacy of health information including the impact of the Health Insurance Portability and Accountability Act rules.
  • Articulate the legal ramifications of disclosure, ownership and security of health information.

Bibliography

Abdelhak, M. Health Information: Management of a Strategic Resource. Philadelphia, PA: W.B. Saunders Co;1996:358-393.

Bruce JAC. Privacy and Confidentiality of Healthcare Information. Chicago, Ill: American Hospital Publishing Inc; 1984:7-18.

Code of Ethics for the Profession of Radiologic Technologists. Revised July, 1994.

Donaldson MS, Lohr KN, eds. Health Data in the Information Age: Use, Disclosure, and Privacy. Washington, DC: National Academy Press; 1994:141-161.

Huffman EK. Health Information Management. 10th ed. Berwyn, Ill: Physicians' Record Company; 1994.

Pozgar GD. Legal Aspects of Health Care Administration. 3rd ed. Rockville, Md: Aspen Publishers Inc; 1987:113-122.

Scott RW Health Care Malpractice. Thorofare, NJ: SLACK Incorporated;1990:15, 27-29.

Southwick AF. The Law of Hospital and Health Care Administration. Ann Arbor, Mich: Health Administration Press; 1978:298-345.

Stone PC, Hilton CF. Medicolegal aspects of emergency department radiology. Radiol Clin North Am. 1992;30:495-501.

Warren DG. Problems in Hospital Law. 3rd ed. Rockville, Md: Aspen Systems Corporation; 1978:273.

Webliography

General Info

Page Name: Medical Records Institute
URL: http://www.medrecinst.com/
Notes: Homepage of Medical Records Institute. Good resource.

Page Name: AMA--Electronic Medical Records
URL: http://www.ama-assn.org/ama/pub/category/3113.html
Notes: AMA resource site on electronic medical records.

Legal Aspects

Page Name: Medical Records Confidentiality Act Of 1995
URL: http://www.lectlaw.com/files/leg20.htm
Notes: Self-explanatory-the Medical Records Confidentiality Act of 1995

Page Name: The Medical Record: Legal considerations
URL: http://info.med.yale.edu/caim/risk/med_record/med_record_5.html
Notes: Brief article on medical record as a legal document. From Yale Med School.

Page Name: WashingtonPost.com: EXPOSED
URL: http://www.washingtonpost.com/wp-srv/national/longterm/exposed/exposed1.htm
Notes: Long, multipage article from Washington Post on, you guessed it, medical records privacy.

Page Name: Privacy
URL: http://www.cptech.org/privacy/
Notes: Resource page with links to articles/info on current privacy disputes/issues.

Page Name: HIMinfo News, Clinton Releases HIPAA's Final Privacy Rules.
URL:http://www.himinfo.com/ Accessed 12-20-00.

Page Name: Medical Record Privacy
URL: http://www.epic.org/privacy/medical/
Notes: Another privacy resource page.

Page Name: Confidentiality and Medical Records Privacy Resources
URL: http://wings.buffalo.edu/faculty/research/bioethics/privacy.html
Notes: More resources on privacy issues.

Page Name: Pitfalls of IV Therapy
URL: http://medi-smart.com/pitfalls.htm
Notes: Article on potential legal problems associated with IV Therapy. Article urges proper and thorough documentation of IV Therapy to avoid malpractice litigation.


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