Chapter 9
Legal Aspects
of Health
Information
Management
Legal & Regulatory Terms
• Sources of law
– Administrative law
– Case law or common law
– Statutory law
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Case Law Principles
• Res gestae “things done”
• Res ipsa loquitur “the thing speaks for itself”
• Res judicata “the thing is decided”
• Respondeat superior “let the master answer”
• Stare decisis “to stand by things decided”
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accessible website, in whole or in part.
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Subpoena Types
• Subpoena ad testificandum
• Subpoena duces tecum
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accessible website, in whole or in part.
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Maintaining the Patient Record in
the Normal Course of Business
• The patient record is a legal business record
• HIM professionals have the responsibility to
secure and manage patient information in
the normal course of business
© 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part.
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Confidentiality of Information &
HIPAA Privacy & Security Provisions
• Privileged communication
• Confidentiality
• Privacy rule
• Security rule
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accessible website, in whole or in part.
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Disclosure Tracking
• Tracking of disclosures must occur and
can be completed using a manual or
automated system
© 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part.
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Legislation That Impacts Health
Information Management
• Conditions of Participation (CoP)
• Conditions of Coverage (CoC)
• Drug and Abuse Act of 1972
• Emergency Medical Treatment and Labor Act
(EMTALA)
• Federal Patient Self-Determination Act
• Freedom of Information Act of 1966
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accessible website, in whole or in part.
(Continues)
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Legislation That Impacts Health
Information Management (Continued 1)
• Health Care Quality Improvement Act of 1986
• Health Insurance Portability and Accountability
Act of 1996 (HIPAA)
• Healthcare Integrity and Protection Data Bank
• Occupational Safety & Health Act of l970
(OSH Act)
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accessible website, in whole or in part.
(Continues)
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Legislation That Impacts Health
Information Management (Continued 2)
• Omnibus Budget Reconciliation Act of 1987
• Omnibus Budget Reconciliation Act of 1990
• HIPAA Privacy Rule: Patient Access to
Records
• Patient Safety and Quality Improvement
Act of 2005
• Privacy Act of 1974
• Uniform Healthcare Information Act (UHIA)
© 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part.
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Release of Protected Health
Information (PHI)
• Know when authorization to disclose PHI is not
required
• Know when authorization to disclose PHI is
required
• Patient access to records
• Prohibition on redisclosure
• Tracking disclosure of PHI
© 2019 Cengage®. May not be scanned, copied or duplicated, or posted to a publicly
accessible website, in whole or in part.
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