KHIMA Legal Manual
Current subscribers need to login in order to access the manual. Not a subscriber? Subscribe today! If you are a subscriber and need assistance, please contact us.
Foreword
This manual was developed by Richelle Marting, JD, MHSA, RHIA, CPC, CEMC, CPMA, CPC-I with Marting Law, LLC.
Copyright © 2023 by the Kansas Health Information Management Association. All rights reserved. Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of Kansas Health Information Management Association.
While every measure was taken to ensure the completeness and accuracy of information contained herein, the authors assume no liability for errors or omissions. This publication is being provided as an educational tool, and any documents, sample policy language, guidance, or instructions contained herein are not intended to provide legal advice. Laws affecting healthcare are complex, and revisions to organizational operations, policies, procedures, and other documents should be reviewed by legal counsel. References cited in this manual were current and valid as of the date of publication. References, including websites, statutes, regulations, and other sources may change periodically. Users should refer to these sources for the most current information. CPT® is a registered trademark of the American Medical Association. The authors make no claim of ownership by mentioning any copyright or trademark mentioned herein.
Table of Contents
Chapter 1: Ethics in Health Information Management
Chapter 2: The Hierarchy of Legal Authority
Chapter 3: The Basics of Health Information
Chapter 4: Creation and Retention of Medical Records
- Initiation of the Physician-Patient Relationship
- Access to Healthcare Services
- Creation and Ownership of the Medical Record
- General Principles for Documentation
- Orders
- Abbreviations
- Timeliness
- Records of Non-Physician Practitioners
- Student Entries
- Scribes and Documentation Assistants
- Authentication: Signature Requirements, Rubber Stamp Signatures
- Changes to the Medical Record
- Storage
- Retention
- Destruction
- Closure or Dissolution of Health Care Facilities or Provider Practice
- Transfer of Care, Firing Patients
- Chapter 4 Checklist
Chapter 5: Privacy of Health Information
- Privileges
- Implied Waiver of Provider-Patient Privilege and Fiduciary Duty
- General Requirements for Confidentiality
- State Law Protection of Personal Information
- Notification of Breach of Personal Information
- Deemed Compliance
- Penalties
- Definition of Protected Health Information
- Minimum Necessary
- Establishing Access
- Mandatory Disclosures
- Permitted Disclosures
- Opportunity for Patient to Object
- Administrative Requests
- Authorizations
- Principles of Disclosure
- Patient Rights to Health Information
- Adoption
- Deceased Patients
- Personal Representatives
- Notice of Privacy Practices
- Information Blocking
- Chapter 5 Checklists
Chapter 6: Genetic Information
Chapter 7: Business Associates
Chapter 8: Electronic Health Information
Chapter 9: Potential Liabilities for Unauthorized Uses and Disclosures
- HIPAA Breaches
- Breach Notification
- Potential Penalties for HIPAA Breaches
- Department of Health and Human Services Waiver of Enforcement
- State Law Considerations
- Invasion of Privacy
- Infliction of Emotional Distress
- Refusal to Disclose
- Medical Malpractice Liability Actions
- Health Information Portability and Accountability Act
- Chapter 9 Checklist
Chapter 10: Third Party Payors
Chapter 11: Debt Collection Practices
Chapter 12: Compliance and Audit Programs
Chapter 13: Medical Staff Issues
Chapter 14: Human Resources
Chapter 15: Specific Providers, Facilities, and Programs
Chapter 16: HIV/AIDS
Chapter 17: Mental Health
Chapter 18: Individuals in Custody
Chapter 19: Death, Autopsy, and Anatomical Gifts
Chapter 20: Informed Consent
- Principles of Informed Consent
- When Consent Is Required
- Exceptions to Express Consent Requirements
- Basis for Consent Requirements
- Capacity to Consent
- Authority to Consent
- Process for Informed Consent
- Elements of Informed Consent
- Duration of Consent
- Investigational Drugs and Experimental Treatment
- Artificial Insemination
- Sterilization and Hysterectomy
- Abortions
- Blood Chemical Tests
- Urine Tests
- Chapter 20 Checklist
Chapter 21: Health Care Treatment Decisions
Chapter 22: Peer Review and Professional Review Documents
Chapter 23: Legal Proceedings
- Discovery
- Privilege
- Admissibility of Electronic Records
- Court Orders
- HIPAA Compliant Production
- Subpoenas
- Objections to Subpoenas and Motions To Quash
- Business Records Affidavit & Outside Records
- Blood Chemical Tests
- Urine Tests
- Requests by Administrative Agencies
- Alternative Dispute Resolution
- Chapter 23 Checklist