Legal Requirements for Maintaining Medical Records Essay

Legal Requirements for Maintaining Medical Records Essay

No 5, 8, 10 and 20: Can you indicate the supporting evidence from the slide Legal Requirements for Maintaining Medical Records Essay

5. Under common law, which of the following relationships was NOT considered privileged? Legal Requirements for Maintaining Medical Records Essay

a. Doctor–patient

b. Attorney–client

c. Priest–penitent

d. Husband–wife

Proof of a patient’s consent is a defense against what type of lawsuit?

a. Harassment

b. Battery

c. False imprisonment

d. Negligence

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10. Proof of a patient’s consent is a defense against what type of lawsuit? Legal Requirements for Maintaining Medical Records Essay

a. Harassment

b. Battery

c. False imprisonment

d. Negligence

20. What is the major legal and philosophical problem with “wrongful life” cases?

a. Determination of the time of birth

b. How to measure damages

c. The statute of limitations

d. The Americans with Disabilities Act Health Administration Press Chapter 10 Emergency Care Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Main Topics • The common law and statutory duties • The standards of federal law (EMTALA) • The duty to exercise reasonable care • Staffing the ED • Good Samaritan statutes Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press The Need for Emergency Care Facilities • Number of ED visits increasing. • Should acute care hospitals be required to have an ED? • Where else can one get emergency treatment? Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Duty to Treat and Aid • Common law rule: no duty to assist • Childs v. Weis (Pregnant women case P.375) • Later, more enlightened judicial decisions to render ER care. • Public employees have a duty to aid victims of accidents and other emergencies. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Statutory Requirements • Some state laws have long required hospitals to treat emergencies. • Discrimination may violate civil rights laws if based on race, creed, etc. • Reports of “patient dumping” in the 1980s led to federal law. • EMTALA (COBRA) 1985: Consolidated Omnibus Budget Reconciliation Act known as (antidumping act) its purpose to provide adequate first response to medical crisis for all patients. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Statutory Requirements • Hospitals, for example, under the Emergency Medical Treatment and Active Labor Act (EMTALA) are required to first provide stabilizing treatment and transfer to an appropriate healthcare facility when necessary. • The courts recognize a general duty to care for all patients presenting themselves to hospital emergency departments. Not only must hospitals accept, treat, and transfer emergency department patients if such is necessary for the patients’ well-being, but they also must adhere to the standards of care they have set for themselves, as well as to national standards. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press EMTALA • The term emergency medical condition under EMTALA has been defined as: (A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press EMTALA (B) with respect to a pregnant woman who is having contractions, (i) that there is inadequate time to effect a safe transfer to another facility before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press EMTALA • EMTALA was not intended to be used as a federal malpractice statute but, instead, was enacted to prevent patient dumping (the practice of refusing to treat patients unable to pay for care). • An EMTALA-appropriate medical screening examination is not judged by its proficiency in accurately diagnosing a patient’s illness, but rather by whether it was performed equitably in comparison to other patients with similar symptoms. • If a hospital provides an appropriate medical screening examination, it is not liable under EMTALA even if the physician who performed the examination made a misdiagnosis that could subject him or her and the employer to liability in a medical malpractice action. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press EMTALA • Hospitals are expected to notify specialty on-call physicians when their particular skills are required in the emergency department. • A physician who is on call and fails to respond to a request to attend a patient can be liable for injuries suffered by the patient because of his or her failure to respond. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press EMTALA (COBRA of 1985) • EMTALA (COBRA of 1985) • Duty to assess, stabilize if possible • May transfer if benefits > risks • Definitions are important • Applies to everyone, whether Medicare-eligible or not Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Ambiguities in EMTALA • What is an “appropriate” screening exam? • When does duty begin? • When has patient come to the hospital? • Does motive matter? Pt inability to pay. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Appropriate Screening Exam • If the exam was negligent, is that inappropriate? • What standard to apply? • Summers case P. 379. • Good faith, no improper motive • Malpractice standard doesn’t apply • Dangerous behavioral health patients Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Legal Requirements for Maintaining Medical Records Essay

Health Administration Press When Duty Begins • When known to have an emergency condition • Subsec. (b)(1): Anywhere in the hospital, not just the ED • Subsec. (c)(1)*: Restricts transfers before the patient is stabilized unless certain conditions are met (patient request, MD certification, etc.) • Injured person outside the hospital entrance (Chicago case) • Now by rule deemed to be anywhere within 250 yards *Not quoted in the textbook Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Duty to Patients in Ambulances • Arrington v. Wong—in ambulance and known to be on the way • In a hospital-owned ambulance • Beller v. Health and Hosp. Corp. of Marion County Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Motive • Early cases held the hospital’s motive must have been related to the patient’s economic status (uninsured, e.g.). • Cleland case raised the issue. • Supreme Court decision in Roberts v. Galen of Virginia holds that an improper motive need not be proven. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Other Considerations • Duty of reasonable care—liability and negligence • Admission or transfer • Staffing the ED • “Good Samaritan” statutes Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Chapter Discussion Questions 1. What is the common law’s traditional viewpoint concerning a bystander’s duty to come to the aid of a person in need? How, if at all, is that duty different today? How might it differ depending on who the bystander is? On the last point, if the “bystander” is a lifeguard, an EMT, a law enforcement officer, etc., they might well have a separate duty to attempt a rescue. 2. Discuss the Childs case with your classmates. Why do you suppose the hospital did not have a physician present or immediately available to assist in its emergency department? Why wouldn’t a physician come to the hospital and personally examine a woman in labor? What were the motives of the parties involved? It was rural Texas more than 50 years ago. At that time, most hospitals, especially in rural areas, did not have full-time emergency physicians on call. As for motives, one might suspect racial bias to have been a factor. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Chapter Discussion Questions 3. Describe a hospital’s duty to a person who comes to the emergency department requesting treatment. Is this duty the same if the person is indigent? The EMTALA duty does not vary based on indigence. 4. In the Arrington opinion regarding what it means when someone “comes to the hospital,” the US Court of Appeals for the Ninth District wrote approvingly of HHS’s position. The HHS regulation states that “it would defeat the purpose of EMTALA if we were to allow hospitals to rely on narrow, legalistic definitions of ‘comes to the emergency department’ or of ‘emergency department’ to escape their EMTALA obligations.” Which is the more “legalistic” interpretation— that of the regulation and the court or that of the person who reads into the plain meaning of the statute? The case is an excellent example of how seemingly simple language can create serious problems of interpretation. How might you have written the statute to avoid the kinds of ambiguities seen in these cases? Copyright © 2020 Foundation of the American College of Healthcare Executives. Legal Requirements for Maintaining Medical Records Essay

Not for sale. Health Administration Press Chapter Discussion Questions 5. Is Arrington the work of “activist judges” who are “making law,” as some claim about decisions they do not agree with? 6. What are the liability hazards of requiring all members of the medical staff to take emergency department duty? See Law In Action on page 365. 7. What effects have Good Samaritan statutes had on the duty to render aid in an emergency? Not much, I would argue. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press The Court Decides • Moses v. Providence Hosp. and M.C., Inc. • Beller v. Health and Hosp. Corp. of Marion County Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Moses v. Providence Hospital and Med. Ctrs., Inc. Discussion Questions 1. What additional information would you like to have about the facts of this situation? • Point out that the case will go back to the trial court for a hearing on the merits. Facts need to be entered into evidence to address such questions as: what did the psychiatrist think on day 5, not just the internist? Were suicide precautions taken as instructed? Did Howard make other threats against his wife while in the hospital for six days? • 2.

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What is the EMTALA standard by which the decision to release this type of patient should be made? Stabilize the patient. • 3. According to the opinion of the court, was that standard met in this case? Trick question. That wasn’t decided; it remains for the jury to decide after a full hearing of all the facts. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Beller v. Health and Hospital Corp. of Marion County Discussion Questions 1. Do you agree that the 2003 amendment was a “clarification” and not a substantive change to the EMTALA regulation? 2. Should the HHS denomination of the amendment be determinative? 3. Why is the named defendant the “Health and Hospital Corporation of Marion County” and not Wishard Hospital? See if students know what “d/b/a” means. It’s a county hospital doing business as “Wishard Memorial,” which was probably its original name before being acquired by the government agency. 4. Had the outcome here favored the plaintiffs, what would the next procedural steps have been and what would the likely outcome of the case be on its merits? Had the decision been different, the case would then have gone to trial on the merits. Students must understand that this decision concerned only the correctness of the granting of summary judgment in favor of the defendant. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Chapter 9 Health Information Management (HIM) Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Main Topics • The purpose of HIM: to keep accurate records that aid in clinical decision making • Definitions of health information, covered entity, PHI, and deidentification • Federal and state privacy laws including HIPAA, HITECH, and “red flags” • The possible civil and criminal penalties for privacy breaches • Use of records in legal proceedings Copyright © 2020 Foundation of the American College of Healthcare Executives. Legal Requirements for Maintaining Medical Records Essay

Not for sale. Health Administration Press HIM • All organizations, regardless of mission or size, develop and maintain information management systems, which often include financial, medical, and human resource data. • Information management is a process intended to facilitate the flow of information within and between departments and caregivers. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Health Information Management (HIM) • The Form, Content, and Purpose of Records Health information management (HIM) in the age of HIPAA concerns not only what we traditionally think of as “medical records”—paper charts with physicians’ progress notes, nursing notes, lab results, etc.—but essentially any information maintained about an individual having to do with their healthcare in any way. So, for example, it includes billing records, which we would not typically think of as being “medical records.” Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Health Insurance Portability and Accountability Act (HIPAA) • Kassebaum-Kennedy bill, Aug. 1996 (HIPAA) • New privacy and security standards • New fraud provisions • New definitions • Health information • Protected health information (PHI) • Covered entity • De-identified information Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Health Insurance Portability and Accountability Act (HIPAA) • Covered entity is a health plan, healthcare clearinghouse, or healthcare provider that transmits any health information in electronic form. • Protected Health Information (PHI) is any health related information that identifies or can be used to identify the individual to whom it pertains (name, date of birth, address, email, URL, SS#…etc. • De-identification: information can not reveal the identity of the individual. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press The primary purpose of medical records • The primary purpose of medical records is of course to document the care given, but there are other purposes too. • The quality of documentation depends on the persons making the entries. Liability increases if quality of documentation decreases. Entries must be relevant to the clinical care. Suppositions, comments about other providers, etc. are inappropriate. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Medical Records: General Principles • Primary purpose = documentation of care • Other purposes: • Medical necessity • Ethical decision-making • Protection of patients and providers • Defense of litigation • Coding and Billing • Accreditation • Per review and Quality Assurance • Research Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Legal Requirements for Maintaining Medical Records Essay

Health Administration Press Medical Records: General Principles • Quality of documentation is important • Improper changes = presumption of “guilt” • What is “authentication”? The accuracy and correctness of information. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Medical Records: General Principles • who owns the records (the provider) and who can have access (many people, including the patient). • HIPAA codifies the patient’s right to have access and a copy of their record and it establishes these other patient rights under certain circumstances: • A right to have a record corrected or amended, if wrong • A right to limit the provider’s use and disclosure of information • A right to obtain an accounting of the provider’s disclosures • A right to a notice of privacy practices • The right to file complaints with the secretary for privacy breaches Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press General Principles (continued) • Form and content • Records retention: Records should be retained at least 5 years. • Ownership and control • Who owns the record? • Who can have access to the information in the record? • Patient matching errors▪ Record not belong to the right patient (False negative) ▪ Information in the record belong to another person (False positive) Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Access to Records • The provider owns the record • Patients have rights to access/copy of record • Control over the use of their health information • Request correction or amendment • Limit use and disclosure • Accounting of disclosures (other than normal treatment, payment, healthcare operations) • Notice of privacy practices • Right to file complaint Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Medical Records (continued) • Timeliness • At time of treatment, observation, etc. • Completed w/in 30 days of d/c • Who can make entries? • How to make changes? • “Superconfidentiality” statutes: mental health, HIV/AIDS, substance abuse Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Medical Records (continued) • Entries must be legible. • A “signature” can include rubber stamps (not preferred but okay if permitted under state law and hospital policy) and electronic signatures. • The proper way to make a change in the record is to draw a single line through the incorrect entry, write “error,” make the correct entry, sign, and date; explain the change if not obvious. NEVER erase, obliterate, use “white out,” etc. Examples of improper entries are shown on pages 331 and 332. No Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Medical Records (continued) • In most malpractice cases, the record is the most important “witness.” Record entries must be timely, and an inpatient chart must be completed with clinical résumé (“discharge summary”) signed by the attending physician within 30 days of discharge. HIM department can suspend the privileges of those physicians who are delinquent in completing their charts. Copyright © 2020 Foundation of the American College of Healthcare Executives. Legal Requirements for Maintaining Medical Records Essay

Not for sale. Health Administration Press Medical Records (continued) • There should be a hospital policy listing who can make entries in medical records. These should include physicians and nurses, of course, but others can make entries too: nursing and medical students, if supervised; social workers; technicians; pastoral care; case managers; etc. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press Medical Records (continued) • Oral orders can be transcribed for certain things by persons given authority to do so by hospital policy. Oral orders must be countersigned by the physician within 24 hours. • The hospital or physician owns the record itself, but the patient has an interest in its contents. Under HIPAA, the patient has the right to review and obtain a copy of their record or have a copy sent to someone of their choice (a new physician, an attorney, etc.). • There are federal and state “super-confidentiality” laws regarding mental health, substance abuse, and HIV/AIDS records. Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Health Administration Press HIPAA Privacy and Security Standards • Due to electronic transactions/medical records • Covers all patient-identifiable data if ever in electronic form • Requires full-time security program • Privacy/security officer, training, monitoring • Huge civil and criminal penalties Copyright © 2020 Foundation of the American College of Healthcare Executives. Not for sale. Legal Requirements for Maintaining Medical Records Essay

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