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Title

Medical Charting and Documentation, Part 3: Legal Aspects of Documentation (0.5 credit hours)

Abstract

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. Course Approval Expiration/End Date: August 1, 2011 Category A Credit

This activity may be available in multiple formats or from different sponsors. The ARRT does not allow CE activities such as internet courses, home study programs or directed readings to be repeated for CE credit in the same or any subsequent biennium.

Author

Katherine Ott, M.S.W., 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.

Objectives

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.

Resources

Bibliography

Abdelhak, M. Health Information: Management of a Strategic Resource. 3rd ed. Philadelphia, PA: Saunders;2007.

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.

Department of Justice Bulletin on Computer Records and the Federal Rules of Evidence. March 2001.

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. 10th ed. Sudbury, Ma: Jones & Bartlett Publishers; 2006.

Practice Brief Maintaining a Legally Sound Health Record � Paper and Electronic, American Health Information Management Association. Revised November, 2005.

Scott RW. Health Care Malpractice. New york, NY: McGraw-Hill;1998.

Southwick AF. The Law of Hospital and Health Care Administration. Ann Arbor, Mich: Health Administration Press; 1993.

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

Warren DG. Problems in Hospital Law. 6th ed. Rockville, Md: Aspen; 1990.

Webliography

General Info
AMA (American Medical Association). AMA CPT (Current Procedural Terminology. Electronic Medical Records. 2009. Available at: http://www.ama-assn.org/ama/pub/category/3113.html. Accessed July 1, 2009.

Legal Aspects
Allen A, Washington Post Magazine. WashingtonPost.com: EXPOSED. February 8, 1998. Available at: http://www.washingtonpost.com/wp-srv/national/longterm/exposed/exposed1.htm. Accessed July 1, 2009.

Consumer Project on Technology (CPTech). Privacy. January 25, 1999. Available at: http://www.cptech.org/privacy/. Accessed July 1, 2009.

Electronic Privacy Information Center. Medical Record Privacy. April 3, 2006. Available at: http://www.epic.org/privacy/medical/. Accessed July 1, 2009.

The 'Lectric Law Library. Medical Records Confidentiality Act Of 1995. Available at: http://www.lectlaw.com/files/leg20.htm. Accessed July 1, 2009.

Masoorli S, Medi-Smart. Pitfalls of IV Therapy. 1999 - 2004. Available at: http://medi-smart.com/pitfalls.htm. Accessed July 1, 2009.

UB (University of Buffalo) Center for Clinical Ethics. Medical Records Privacy Resources. Available at: http://wings.buffalo.edu/faculty/research/bioethics/privacy.html. Accessed July 1, 2009.

Yale-New Haven Medical Center. YNHH Risk Management -- The Medical Record. Legal considerations. 1997. Available at: http://info.med.yale.edu/caim/risk/med_record/med_record_5.html. Accessed July 1, 2009.