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Ch15 Hlth Inf Mngmt
Privacy & Health Law
| Question | Answer |
|---|---|
| legal written document specifying patient's preferences regarding future health care or specifies another person to make medical decisions in event patient had incurable/irreversible condition & is unable to communicate wishes; patient must be competent | advanced directive |
| rather than settling dispute in court, neutral party/panel hear both sides & renders decision, or by settling claims against them by negotiating direct payment to party bringing claim in exchg for clmt dropping the claim | alternative dispute resolution |
| laws prohibiting anti-competitive behaviors such as price discrimination, restraint of trade, and monopolies | antitrust |
| settling of a dispute outside of court through neutral party/panel | arbitration |
| deliberate threat, coupled with apparent ability to do physical harm to another person without that person;s consent; no contact is required | assault |
| process of verifying/confirming identity of a user that is requesting to access the information | authentication |
| context of patient authorizing disclosure of their protected health information; refers to written permission that meets requirements of applicable law that is required to be able to disclose the info | authorization |
| courtroom personnel who are present to assisting keeping order, administering oaths, guarding & assisting jury, & performing other duties at direction of the judge | bailiff |
| nonconsensual, intentional touching of another person in socially impermissible manner | battery |
| rules of evidence require that when originals are still available, they must be produced. when it becomes necessary to prove contents of a document, original must be produced or its absence accounted for. | best evidence rule |
| when one part to a contract fails to follow the terms agreed to in the contract | breach of contract |
| when a plaintiff brings a civil suit against a defendant, unless plaintiff can convince judge/jury by a preponderance of evidence that claims against defendant are valid, the defendant will prevail | burden of proof |
| special agreement required by HIPPA that covered entities must use when using outside agents/organizations to handle/process protected health info on their behalf; ensures the agency follows rules set by covered entity for handling protected health info | business associate agreement |
| in deciding on cases when no statutes apply, judges refer to similar cases that have been decided in past & by applying same principles, courts generally arrive at same ruling in current case as in similar previous cases | case law |
| doctrine that has, until the early=mid 1960s, protected nonprofit hospitals from liability for harm to patients; courts now permit harmed patients to sue hospitals for their wrongful acts | charitable immunity |
| administrative manager of court who handles paperwork associated w/lawsuits; complaints are filed w/clerk, as are pleadings & documents | clerk of the court |
| large body of principles that have evolved from prior court decisions | common law |
| written statement by plaintiff that states claim & commences the action in a lawsuit | complaint |
| communication that transmits info to health care provider as part of relationship between provider & patient under circumstances that imply that info shall remain private | confidential communications |
| written permission from patient allowing care/treatment | consent |
| documentation made while care is being provided, while the info is fresh in care provider's mind | contemporaneous documentation |
| formal & binding agreement; actual/implied | contract |
| under this theory, courts can hold HCOs liable for their own independent acts of negligence | corporate negligence |
| written/verbal order issued by the court | court order |
| individual responsible for creating verbatim transcript of court proceedings | court reporter |
| any entity that is a health plan, health care clearinghouse, or health care provider conducting certain transactions in electronic form & must comply w/HIPPA's Privacy Rule | covered entity |
| process of granting/renewing certain privileges to practice medicine to prospective/existing members of medical staff at a facility | credentialing |
| oral/written communication to person (other than defamed) tending to damage the defamed's reputation in eye's of community | defamation |
| party(s) in a lawsuit from whom relief/compensation is sought from the plaintiff | defendant |
| refers to data that have been stripped of certain patient identifiers | deindentified |
| sworn verbal testimony | deposition |
| HIPPA terms used to include records that contain protected health info maintained by/for a covered entity | designated record set (DRS) |
| process whereby each party is party a lawsuit seeks to discover important info about case through a pretrial investigation | discovery |
| the right to a full hearing | due process |
| a competent adult names in writing another adult to make any medical decisions on their behalf in the event they become incapacitated. | durable power of attorney for health care |
| minors who can make their own health care decision without parental/guardian involvement | emancipated minor |
| information legally presented at trial, offered to prove or disprove an issue under contention | evidence |
| unlawful restraint of person's personal liberty or unlawful restraining/confining of a person; physical force not required only that there is reasonable fear that force will be used to detain/intimidate the person into following orders | false imprisonment |
| willful & intentional misrepresentation that could cause harm/loss to a person/person's property | fraud |
| HIPPA terms used to describe activities that may need to use/reference protected health info, when use is directly related to operation of health care entity & handled appropriately | health care operations |
| bars legal admissibility of evidence that is not the personal knowledge of the witness | hearsay rule |
| paper-based/electronic report completed by health care professionals when a variance occurs from usual process of patient care/when a mishap/injury occurs involving a patient, staff member, or visitor | incident report |
| research & human rights advisory board, part of most healthcare facilities & universities meeting at least quarterly | institutional review board (IRB) |
| claims pertaining to intentional harm | intentional tort |
| form of testimony | interrogatory |
| negligent disregard for patient's privacy | invasion of privacy |
| power of a federal, state, etc. court to hear a dispute | jurisdiction |
| written document allowing a competent adult to indicate their wishes regarding life-prolonging medical treatment should they be unable to consent | living will |
| professional negligence | malpractice |
| principle of HIPPA privacy rule, only minimum necessary amount of info necessary to fulfill purpose of request should be shared w/internal users & external requestors | minimum necessary |
| motion files by legal counsel in which court is asked to set aside the subpoena/order | motion to quash |
| conduct that society considers unreasonably dangerous; failure to provide a reasonable level of care. | negligence |
| factual summaries of unexpected events that have/could have resulted in injury/harm to patients/staff/visitors. | occurrence report |
| party that initiates the lawsuit | plaintiff |
| when defendant files an answer to the complaint from the plaintiff | pleading |
| legally recognized authority to act & make decisions on behalf of another party | power of attorney |
| rulings of similar previous cases | precedent |
| override | pre-empt/pre-emption |
| when weighing whether something is true/not true when evidence supports the case by 51% | preponderance of evidence |
| right of individuals to control disclosure of their personal info | privacy |
| statements made to attorneys, priests, physicians, spouses, or others in a legally recognized position of trust | privileged communication |
| HIPPA rule that any individually identifiable health information should be kept confidential | protected health information |
| primary or substantial cause of an injury | proximate cause |
| whistleblower-based prosecutions | qui tam |
| if a claim involves simple, not professional, negligence the jury uses this standard to evaluate the defendant parties' conduct in light of jury's own general experience & background | "reasonable man" standard |
| dictates of government agencies charged with enforcing & implementing legislation in a particular area; dictates are designed to carry out the intent of the law | regulation |
| doctrine: HCOs must take reasonable steps to supervise actions of their employees/professional staff, incl. medical staff | respondeat superior |
| contracts/agreements that tend to/are designed to eliminate/stifle competition, create a monopoly, artificially maintain prices, or otherwise hamper/obstruct course of trade/commerce | restraint of trade |
| constitutionally recognized right to be left alone, to make decision's about one's own body, & to control one's own info | right of privacy |
| subpoena duces tecum validity for hlth info under HIPPA: reasonable efforts by party seeking info ensuring subject of protected health info given notice of request or has secured qualified protective order that meets HIPPA privacy rule | satisfactory assurance |
| HIPPA & good business practices require HCOs implement administrative, technical, & physical safeguards to protect confidentiality, integrity, & appropriate availability of hlth info maintained in paper/electronic format | security of health information |
| generally accepted standards for each profession determined by referring to current standards published by relevant specialty society & professional literature | standard of care |
| legal principle that courts should decide similar cases similarly; cases with similar facts & questions should ordinarily be decided in the same way | stare decisis |
| law enacted by Congress or state legislatures | statute |
| law requiring claims to be filed within certain period of time; otherwise claims will not be heard by a court | statute of limitations |
| written court order that requires someone to come before the court to testify | subpoena |
| written court order that requires someone to come before the court & to bring certain records/documents named in that order | subpoena duces tecum |
| action where one party alleges another party's wrongful conduct has caused them harm; the party bringing action to court seeks compensation for that harm | tort |
| individual who goes outside regulatory bodies in an org. to raise a problem rather that reporting a suspected unlawful activity internally | whistleblower |
| authorized employees of an org. as used in the HIPPA privacy rule | workforce |
| alternative dispute resolution is also referred to as | mediation / arbitration |
| applicant's background reviewed, licenses/certifications checked, proof of current liability insurance verified & practice patterns/quality review data evaluated to determine whether privileges should be granted during | the credentialing process |
| responsible for monitoring activities of people who function within their facility whether employees or independent contractors & for complying w/ appropriate industry standards under | the corporate negligence theory |
| when referring to the corporate negligence theory, the appropriate industry standards refers to | the Joint Commission standards, licensing regulations, & Medicare's Conditions of Participation |
| oral defamation of character that tends to damage the defamed's reputation in eyes of community | slander |
| written defamation of character that tends to damage the defamed's reputation in eyes of community | libel |
| to encourage our-of-court resolution of cases by acquainting all parties w/pertinent facts | discovery phase |
| depositions & interrogations, during the discovery phase, are considered | pertinent testimony |
| in addition to pertinent testimony, the discovery phase includes obtaining ___ under the control of the opposing party | documents |
| when referring to a durable power of attorney for health care, the extent of the decision-making power varies from | state to state |
| under the law an emancipated minor is treat as an adult & have the right to consent to treatment & authorize | disclosures of their health information |
| if information is allowed to be used at trial it can be | "admitted into evidence" |
| interpreted & applied by judges in deciding what info can be admitted into evidence & both federal gov. & individual states have | rules of evidence |
| conducting quality improvement activities, contacting patients w/info about treatment alternatives, providing w/educational info, evaluating practitioner/provider performance, accrediting, licensing & credentialing are HIPPA's definition of | health care operations activities |
| during HIPPA's health care operations activities no specific ___ is required on the part of the individual(s) whose info is being accessed | authorization |
| incident reports are meant to be nonjudgmental, ___ ___ of the event & its consequences, if any | factual accounts |
| incidents reports are prepared to assist in identifying & correcting problem-prone areas & in preparation for __ __ | legal defense |
| is to protect human subjects/patients from research risks & invasion of privacy, by reviewing all research studies that involve subjects/patients, incl. experiments, interviews, questionnaires, & any study data from patient's MR | the aim of an IRB |
| assault & battery, false imprisonment, defamation of character, invasion of privacy, fraud/misrepresentation, & intentional infliction of emotional distress are all | claims falling under intentional tort |
| are sworn written answers to questions | interrogatories |
| uses or disclosures for treatment purposes & where patient has specifically authorized release of more info are (2) of only a few situations where the minimum necessary standard | does not apply |
| occurrence reports are used by HCOs __ __ or __ to investigate incidents that have potential to become claims against org./provider & identify areas where improvements are needed | risk managers & attorneys |
| in a pleading the defendant ___ or otherwise responds to the defendant's claim | denies |
| preponderance of evidence is considering | "more likely than not" |
| the confidentiality of privileged communications is generally protected by law from being ___, even in court | revealed |
| determining the proximate cause of an injury is often a difficult question involved in ______ litigation | negligence/malpractice |
| under respondeat superior, organizations can be held liable for damages when their employees | fail to perform their duties adequately |
| restraint of trade is when the medical/professional staff credentialing process interferes with a physician's/health professional's ability to | pursue his/her profession |
| right of privacy is an important ___ ___ for the health care community | constitutional right |
| HIPPA's focus for security of health info is on protected health info in __ __ | electronic format |
| stare decisis | "let the decision stand" |
| statute of limitations are designed to encourage | timely filing of claims |
| timely filing of claims, under the statute of limitations, allows for the evidence to be fresh and | witnesses to be available |
| in most states the statute of limitations begins at | the time of the event |
| statute of limitations in a health care case begins at the __ __ __ if the patient was treated as a minor | age of majority |
| tort takes place in | private law |
| must be completed as soon as they are detected using the proper methods outlined in facility's policy/procedure manual | error correction |
| in situations where simple error correction methods are insufficient | addenda |
| when a patient asks for an amendment to their records HIPPA's privacy rule permits such requests, but only for facility's operated by | the federal government |
| if a physician believes that an amendment request is inappropriate, reason falling under permissible reason under HIPPA privacy act for denying the change, physician must | speak with patient in regards |
| patient's amendment requests should be handled as an addendum to record without | changes to the original entry |
| outlines an appeal process that must be made available to patient if their request for amendment is denied, & they wish to appeal denial | Section 164.526 of HIPPA privacy rule |
| includes "personnel & medical files & similar files, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy" | (1) of (9) exempt categories under FOIA |
| info must be contained in personnel, medical, or similar file; disclosure of info constitutes invasion of personal privacy; severity of invasion must outweigh public's interest in disclosure; interpreting 3-part test subject of a number of court cases | "unwarranted invasion of privacy" under FOIA |
| it is generally accepted that the facility owns | the health record itself |
| is subject of patient's ownership interest in the info within the record | exercise of ownership rights by the facility |
| authorizations that do not contain all required elements are considered | invalid authorizations |
| releasing info when there is an invalid authorization, is a violations of the HIPPA privacy rule and | can result in penalties |
| internal uses for disclosure for patient care purposes should be on a | need-to-know basis |
| HIPPA's privacy rule permits disclosure of protected health info for treatment purposes | without authorization |
| patient care, quality review, financial, legal, education and research are all___ uses of the PR | legitimate |
| a HIM professional does ___ & ___ analysis of each patient record to assure it consistency and completeness. | qualitative & quantitative |
| a HIM professional facilitates record-keeping for professionals by providing transcription services and developing the most efficient | procedures for record completion |
| a HIM professional ___ all records and prepares them for ___. | codes; billing |
| a HIM professional guards the ___ of records and supervises their transmittal to those authorized to see them. | confidentiality |
| a HIM professional participates in quality assurance, utilization review and ___ activities. | risk management |
| a HIM professional provides __ __ to various medical staff activities. | record-keeping services |
| data for board certification of physicians, management planning, research, regulatory agencies, & special/financial reports are provided by | a HIM professional |
| "The patient has not received all of the services he needs and deserves if his " | record is not current and complete |
| In court, the medical record IS the care rendered. If it isn't in the record," | it didn't happen |
Created by:
lfrancois
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