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Legal Aspects of Health Care Records
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TOPIC: Legal Aspects of Health Care Records
#779
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Chapter 3
Cheily Chiu
1- A court order is issued by a judge that pressures an action, for example a testimony or production of a record.
A subpoena is to compel ones appearance at a certain time and place for testimony.

2 The custodian is the one in charge of determinate what part of the health records can provide evidence to be release or exposed.
The authenticity of the records to assign responsibility, sign affidavit says the record are true and correct copy of the original, determinate is the request is valid and if it meet the state requirement.
Medical record can discuss about the content of the records like diagnosis, procedure, medication, treatment or interpretation because only the author can declare about it.

3-All states have their own rules the Supreme Court approve. Federal rules for example amendment they should be implemented in a state federal court.
4- Normally the judge and the lawyer give a short but descriptive story of how the case is. One interested to become a juror must be at least eighteen years of age, a us citizen of the state and a resident of a county, must not be mental disable who ever not prejudiced by race or gender& religion ,the juror must speak and write proper English.
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#782
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 3
Is there anyway that as an instructor i may have the ability to delete some of the responses that my students submit?
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#783
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 3
Chapter 4 Discussion Questions
Due November 13, 2011

1. Explain various types of legal cases in which health records can provide pivotal evidence.

2. Describe the differences between discoverability and admissibility. Why does the law distinguish between the two? In a medical malpractice negligence case, what types of information might be discoverable but not admissible?

3. Discuss six ways in which electronic records differ from paper records. How do these differences affect the evidentiary value of health records?

4. Explain how one of the amendments to the Federal Rules of Civil Procedure, relative to the discovery of electronic data, will affect a health information or informatics professional.

5. Describe the steps that a health care provider must take when responding to a subpoena duces tecum for a patient’s health records.

6. Why is the health record generally an exception to the rule against hearsay?

7. Under what circumstances may the physician-patient privilege be waived?

8. Why are incident reports not considered part of the health record? How can a healthcare facility assure that the medical record is not considered as part of the health record?
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#784
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 3
Chapter 5 Discussion Questions Due November 13, 2011

1. What are the different type of torts and the various defenses to these torts?

2. What are the causes of action for improper disclosure of health information? Of these, which seem the most likely to succeed? The least likely to succeed?

3. A cause of action for the improper disclosure of health information may result from either a negligent or an intentional act. Using the elements of negligence, give an example of a negligent disclosure of health information. Using the element of intent, give an example of an intentional disclosure of health information.

4. What is an immunity defense in regard to tort liability and who may rely on this type of defense?

5. What is a statute of limitations defense? Describe the different times at which a statute of limitations may begin to run.

6. How do tort and contract law differ?

7. What factors are thought to contribute to rising costs in health care and malpractice insurance rates and what specific tort reform measures exist to address them?
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#787
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Martha Soto
Chapter 1 Discussion Questions

1. Privacy, confidentiality, and security is important because all information, diagnoses, and procedures for each patient needs to be kept private.
Its related to health information because a person's health record contains very intimate personal information and it should be kept that way. It's not for public knowledge.

2. The patient owns the record and controls the use of information. The patient has the right to access, view, copy or amend the record.

3. The role of the custodian of health records is to show responsibility for the care, custody, control and proper safekeeping of the health record.
The director of the HIM department is traditionally appointed this role.

4. The American Medical Association has upheld the preservation of patient confidentiality through its Principles of Medical Ethics since 1847, most recently updated in 2001.
Health information professionals also follow a code of ethics to protect the privacy of the health record.
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#788
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Martha Soto
Chapter 2 Discussion Questions

1. I believe that the government should be solely responsible for criminal prosecution. Everyone would be treated and tried equally.

2. I think that Medicare should be handled by the government. The government I believe would enforce more control and stricter regulations. In recent years it has been shown how much fraud can be done by private companies and individuals.

3. I think that common law is very important. It's not a decision that favors a certain side, it's a court system that comes to an unbiased conclusion and decision.
No, I don't think our society would be successful without these sources of laws. We need laws, regulations, and structure for everything to run orderly.

4. The separation of powers helps to limit the authority of each branch, in order for no one branch to have more power than another.
Executive branch- It enforces the law including issuing regulations by administrative agencies.
Legislative branch- In charge of enacting laws in the form of statutes.
Judicial branch- To interpret the law and adjudicate disputes, creating the common law.

5. I think that the requirements that need to be met in order to appeal to the higher courts are suffice. I believe that cases that proof meeting those requirements are the ones being allowed to show their cases.

6. T believe that mediation is better because both parties come to an agreement that they both agree on. Which to me means that they are both satisfied with the outcome. Not like in arbitration, where it's decided by a third party.
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#789
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Martha Soto
Chapter 3 Discussion Questions

1. A court order is a document issued by a judge that obligates a certain action. Such as a testimony by an individual, or the production of a document such as health records.
A subpoena is a legal tool that obligates someone to appear in court, to provide their testimony or the production of documents or items pertaining to the case, either during the investigation, or at trial.

2. The custodian of health records can only answer questions about the health record, for example where health record has been located, that the information on it has not been altered in any way and is accurate.
They can not answer questions about the information inside the record. Patients personal information, tests, procedures, and results.

3. The purpose of The Federal Rules of Civil Procedure is that every case that comes to court has to follow the same procedure, steps. So every case could be tried equally and abide by the same rules.

4. Attorneys are given discretion to excuse potential jurors "for cause" for example a prosecutor can excuse someone if they will not vote yes on the death penalty due to moral or religious grounds.
Attorneys may not dismiss potential jurors based on race, gender, religion, and ethnicity.
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#798
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 3
Chapter 6 Discussion Questions Due November 13, 2011

1. Explain the differences between express and implied consent. Which type is more legally sound? Are express consents ever given by patients? If so, give examples.

2. If you were undergoing an invasive medical procedure, what information would you want to know prior to giving (or not giving) your consent?

3. Discuss situations in which informed consent is not legally required. From a public policy standpoint, do any of these exceptions to the informed consent requirement seem problematic?

4. Explain different types of advance directives and the pros and cons of each.

5. Discuss situations in which minors may be legally permitted to consent to their own medical treatment. Should they be permitted to make their own treatment decisions in these cases?
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Last Edit: 2011/11/10 09:21 By kristen.
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#803
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
EVIDENCE
Chapter 4, discussion Yarmi Mendez


1) Health Record is essential tool to understand and determinate the way certain action impact the patient and define responsibilities. When plaintiff want to prove injury, health record will be a clear and concise tool in any legal process
It can be use in civil or criminal case like
-Medical malpractice, refer to professional negligence for example surgical mistake like some time surgeon leave inside the body any instrument or when the make amputation on the wrong limb.
-Work compensation when some one has a laboral accident.
-Can help determinate paternity of a child
-Proof fraud and abuse in medicare
-Proof disability
-In crimes cases know as forensics; which is the process used to gather information intact to be use as evidence. Through this science we can evens solvent old case and make easy to identify sex offenders.

2) Discoverability mean that the evident may be or not be relevant to the case and was not the direct cause of the injury.
Admissible are evidence that can be introduce in court.
The law distinguish between the two because in important defined what evidence are relative to the case with the one is not.
The type of information might be discoverable but not admissible depend on specific federal and state rules evidence, statutes and case law.

3) The 6 way electronic record differ from paper health record are:
-Volume and duplicability, which mean any information delete can be easy retrieve.
-Persistence which mean; paper medical record can be destroy by human or natural disaster, but EHR can be erase from computer’s storage device.
-Metadata; is electronic resource information for the software and is not part of the HER like pop-ups, code.
-Dynamic Changeable Content, which means that, is easy to modify than paper.
-Environment-Dependence and Obsolescence; HER need standard function call interoperability, which mean when data is move to other place may can not be display because lack of communication.
-Dispersion and Searchability: EHR is easy to storage, manage and retrieve and can be locate in different device like PDA, disk, etc.

4) One of the amendment approve by United State Supreme Court is about e-discovery rules which apply to parties involved in civil cases. The new rule of Civil Procedure establish that the custodian of the record must appear in court to testified because is the person most familiar with the health record and can help court understand the information required

5) The steps health care provider must take to respond a subpoena if the is paper records:
- Review health record of the patient
- Verify that health record is complete
- Verify that patient name is in each page
-Number each page
- Prepare index
-Make photocopy exactly like original (shadow record)
- Deliver document personal or if it is sent by mail obtain proof of receive.
If the record is electronic or hybrid print only the part is relative to the case, which can be, consider like originals.

6) As general rule hearsay is considerate unreliable information but health record is exception because:
- Is produce under regular course of business.
- Record was entry by a person with knowledge.
- Record was kept in a consistent manner according to a set procedure.
- Record was made at or near the time that the record act, event or condition occurred or reasonably soon thereafter.

7) Patient always has the right or privilege to protect personal information and physician to maintain confidence of that information. In the process of discovery in the trial may is necessary disclosure of privileged patient information material like:
-When information is subjed to public observation.
- Information obtained during employment or pre employment physical exam.
- Information obtains outside treatment setting.

8) Health Record is a legal document that can be use in court and recorded by knowledge person in a course of the business which storage information, observation, treatment, therapy, etc. of patient. By law it can be release in court.
Incident Report, is a report fro any incident that occurred unexpected, It is created to internal investigation, identify and take corrective action.
The data collected in incident report provide information to improve organization performance, law protects it as evidence in court because is not part of patient health record and is only for internal use of the organization.
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#804
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
TORT LAW
Chapter 5, discussion Yarmi Mendez

1) There are 3 different of tort:
Negligence, which mean unintentional behavior
Intentional, which mean intentional behavior
Strict Liability, which mean abnormal dangerous activities are carried and in cases involving injuries caused by wild animal

2) Every employee must follow HIPAA privacy rule of health information disclosure. Improper disclosure can be
-Defamation: False testimony that harm a person
-Invasion of privacy: Expose private information
-Breach or confidentiality: Any relation base on trust and is broken
- Infliction of emotional distress: Intentional disclosure of information that produces emotional distress.
To me the one who seem the most likely succeed are is invasion of privacy and the one least is breach of confident

3) When administrative employee of the hospital see a blood test in the fax for X patient.
This employee comment about it with other employee in inappropriate manor inside the hospital aloud and patient or some relative ear the comment
-Employee violated invasion of privacy when got to see test result that had nothing to do with her job.
-Defamation because the way they were talk was not appropriate that lends it to misinterpretation.
-Breach of confidentiality, because hospital employee attended HIPAA training session and sign policy code of privacy and confidentiality. They know better.
-Infliction of emotion distress because patient after hear how employee talked about her case get emotional distress

4) Immunity defense in regard to tort liability is a group of person or entities that have special protection to legal action there are:
-Government, have immunity refer as sovereign immunity
-Good Samaritan Statutes

5) Statute if limitation is a law that give reasonable period of time to introduce a lawsuit, the reason why limit the time are because evidence can get destroy, people tent to forget, companies change personal and other.
It varies according to each state and the type of tort, as a general rule when the act or omission causing injury is complete and when damage is sustained and is ascertainable.

6) Tort law is the right of individual, corporation or other entitles to recover damage for loss caused by defendant
Contract is a civil law agreement between 2 parties.

7) If we compare the amount of doctor suit for malpractice a year with total of the doctor who practices medicine, I think insurance company abuse, this is one of the reason of rising cost on health care.
In other hand we had the increase of chronic disease, rise of old population, increase of administrative cost, new technology, all this factor also contributed to increase of cost of health care.
The government is trying to make some changes in the healthcare system to improve it and make it more accessible by reducing cost. One of the most important change is the reform of medical malpractice which are already implemented in few states, there are:
-Join and Several Liability: the reform said that a tortfeasor is liable for the proportion of the injury it causes
-Collateral Source Payment allow court to consider collateral sources payment
-No economic and Punitive Damages required standard of proof before punitive damage may be awarded.
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#805
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
CONSENT AND TREATMENT
Chapter 6, discussion Yarmi Mendez

1) Consent is right we give some one in this case for medical treatment and there are two type:
-Express is give to a patient in an oral or writes form to sing and approve treatment
- Implied Is when implicit agreement that is communicate by person’s conduct.
Both are perfectly legal because when a person coming unconscious can not sign or approve any treatment and doctor assume implied consent, it is perfect legal and express consent is always give to a patient before any procedure or visit to a hospital explain risk, benefits and alternative.
If the patient is conscious Express Consent must always give to inform medical procedures, tests, benefits
If the patient is minor them legal guardian must sign
If the patient is unconscious and the performance is necessary not need sigh

2) Physician always should disclose all relevant medical information to a patient before any invasive or test procedure it would be
- Diagnosis and condition
-Explain and descriptive the proposed of test, procedure or treatment
- Adverse effect or risk and benefits
- Recommended test or treatment options

3) The situations in which informed consent is not legally required there are
-Emergency Situation in minor or adult are in life threatening,
- Procedure to a legal incapacitated and parent or legal guard is not available
-Public disclosure of clinical investigation or researchers of the study to interest of the community.
Provider always have a risk of liability and a concent is a way to protect their self.

4) Advance Directive is a document that can be complete before an emergency occurs
with a patient wishes, there are different type
- Durable Power of Attorney for Healthcare Decision is a written document that a person makes before get incapacity to manage your financial affairs, make health care decision or conduct business for the patient,
-Living Wills is a legal document that a person uses to make know his wishes regarding life prolonging medical treatment.
- Do not Resuscitate Orders is a legal order written use in a health care facility which specified providers should not perform CPR on individual with cardiac arrest or cessation of breathing.
-Patient Self-Determination is an act requires in all health-care institutions that receive Medicare or Medicaid funds to provide patients with written information about their right under state law to execute advance directives, but it does not require states to adopt or change any substantive laws. The written information must clearly state the institution's policies on withholding or withdrawing life-sustaining treatment.
- Uniform Anatomical gift Act make sure that the donation of organ is followed in an ethical manner.

5) Children and Consent. Minors may have appropriate decision-making capacity; they usually do not have legal empowerment to give informed consent. Therefore, parents or other surrogate decision-makers may give informed permission for diagnosis and treatment of a child, preferably with the assent of the child whenever possible.
In most cases, parents are assumed to act in the best interest of their child. But circumstances may occur where there is a conflict between what the parents and the health care providers feel is in the best interest. State laws cover some of these areas of potential dispute, for example, in cases of suspected child abuse.
Other disagreements in care may result in court orders that specify what treatment should occur (for example, blood transfusions), or in the court-ordered appointment of a guardian to make medical decisions for the child. Most states have laws that designate certain minors as emancipated and entitled to the full rights of adults.
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#806
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Answers to Chapter 4 Patricia

1. Health records can be used as evidence in cases of injury or malpractice issues. In these cases the plaintiff must prove the wrongful actions of the doctor or medical facility. Information contained in the health record is a recording of steps taken in the continuum of care of the patient. If there is a wrongful act or mistake, the information should be recoverable from the health record itself. Evidence from health records can also be used in court in cases of custodian, criminal and white collar cases.

2. Discoverability is any information exchanged in pretrial or trial between two sides that is applicable to the case. To be admissible the evidence must be related to the pending case. Admissibility refers to discovered information that is admissible in court because it is relevant to the case. The law distinguishes between the two because there may be information known about the case but does not apply to the specific details of the case at trial. Example: A patient can prove injury on paper, but cannot prove it is due to the specific nature of the current trial. The law distinguishes between the two to protect the rights of the defendant. In a medical malpractice case the medical information regarding an injury may be discoverable but not admissible because the plaintiff cannot prove the injuries are specifically due to the doctors negligence. The discoverability depends on state and federal rules of evidence, statues and case law.

3. 1) Volume and duplicability - electronic records cut down on the volume of paperwork and storage area needed to store data. Duplicate records are almost eliminated with electronic records ,because everything is filed in the computer and then can be printed if needed. They save time and space.
2) Persistence - it is easier to arrange or dispose of old data. This information is still on a hard drive that can be retrieved, but you don't have to physically shred pages like you do for paper records.
3) Dynamic Changeable Content - It is much easier to change or correct documents fot spelling erors and mistakes in an electronic record. In paper records, you cannot delete anything. You have to draw a line through it and rewrite the correct information. Electronic records you can just delete and correct..
4) Metadata - Basically this is date about data. It is information that helps the computer or user to assimilate information or in storing and retrieving date later.
5) Environment Dependence & Obsolescence - This is like a computer binary code or computer based language code that computer system must have. The computer must have software to read the information once data is moved.
6) Dispersion & Searchability - It is easier to search for specific information on electronic documents than on paper records. It cuts down time looking for specific information in a patients file. You can usually just enter key words and go right to the information needed. This information can be transfered to or retrieved in a number of electronic devices making it easier to search and store date in a patients record.
These different methods of search and storage cut down on the possibility of errors and the value of the evidence retrieved is more accurate.

4. a) Scheduling orders-outlines key deadlines b) Initial disclosures - mandatory disclosure of basic information c) Reasonable access-allows or discovery of ESI to be limited if it is not reasonably accessible due to cost or undue burden d) Discussion between two parties - states that the parties in hte case must confer with each other for preservation & discovery of the overall discovery plan. e) Interrogatories & production of documents - states information must be produced in the form in which it is normally maintained & one that is usable f) Failure to make disclosures - the court cannot impose fines on a party for not providing ESI if the data is lost in routine operations g) Testing & sampling of documents - is where large volumes of documents are presented & the documents are tested or sampled to make sure they apply to the case .
I believe testing and sampling is one very important area. The HIM professional will need to be envolved early on in the discovery to help decide what information is preserved & what format that information will be presented in. This could involve a lot more than just copying paper records. Information from ESI could involve erased files - retrieved by computer forensics , emails, or files from PDI or other hand help devices.

5. The healthcare professional should verify the case docket number to validate the case, also the date, time and place requested for appearance. They should verify the information requested and specific documents that have been subpoenaed. The form of the documents need to be verified, the name of the attorney, the name of the patient & the person being subpoenaed. The stamp of the court & signature have to be verified. The HIM professional must also verify if the authorization of the patient is required.. The person preparing the documents for a subpoena must produce them as they were kept in the normal course of business & organize and label the documents in the order they were requested in the subpoena. They must follow the steps outlined by the facility defining what constitutes a health record.

6. Hearsay is a statement made outside court. Medical records are documented during the normal course of business and recorded as such. Hearsay isn't admissible unless the information was transmitted with knowledge it was ( kept/reported) maintained during the normal course of business & it was the regular practice of the business activity. Also, any records of pain, past or present, or sensations or treatment regarding medical history are exempt in that they are reasonable & relevant to diagnosis and/or treatment. Statements made for the medical diagnosis & treatment & recording of business records are an exception to hearsay.

7. Physician-patient privilege may be waved in the instance of abuse or child abuse and in the testimony in court requested by a court order. The privacy of information between the physician & patient are protected by the AMA's Ethic principals unless otherwise stipulated by the law. Likewise, medical information obtained for employment is not privileged. It is not considered a patient-physician relationship because it lacks the contractual bond.

8. Incident reports are considered private and are internal information of the company or facility and not subject to disclosure. Copies of incident reports need to be marked private and kept confidential. Copies of these reports should be limited and distributed only to persons on a need to know basis. A healthcare facility can make sure the medical incident reports are kept separate from healthcare records by not recording this information in the medical record..
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#807
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Answers to Chapter 5 Patricia

1. There are two different types of tort law - intentional and negligence. Included in the intentional tort would be battery, assault, false imprisonment, and intentional infliction of emotional distress. In an intentional tort, the law would attempt to provide a remedy for battery, which is any contact to a person against their will, The defense may be that the touching was by mistake or unintentional.
Assault- - the defense would attempt to defend the harmful or offensive contact, such as false accusations or verbal abuse. Perhaps the defense would include self defense or a misunderstanding of the spoken words used in the instance. .
.. False Imprisonment - the defense could be why the intentional confinement was not necessarily against a person's will or that it was done for the persons protection, such as medical confinement, and that no harm was intended.
Intentional infliction of emotional distress - could possible be defended with the stance that the act was done for a persons own good and not intended as distress. The fact that the defendant acted without reckless regard for the plaintiff's feelings would have to be proven.
Negligence - is an unintentional tort. It is usually where the act that was committed states the defendant didn't act in a prudent way.
a) Nonfeasance - is failing to protect a patient from injury or harm. A possible defense could be that the patient didn't follow the doctor's orders and contributed to their own harm.
b) Misfeasance - is the act that causes injury to another person. The defense could be that it wasn't intentional and other factors contributed to the deterioration of the patient.
c) Malfeasance - is conduct that was meant to cause harm. A possible defense could be ignorance and that the intent was not intentional.

2. Causes of action for improper disclosure of health information are either intentional or due to the negligence of the staff. There are four elements that have to be present to prove negligence - duty, breach of duty, injury, and a causal relationship between the breach and the injury. 1. Duty - a person must conform to an indentified and defined standard of duty. 2. Breach of duty -a disregard or breach of duty or a variation from the standard of care. 3. Injury - the injury must be established. The fact that a person was injured or harmed must be proven. 4. Causation -the cause must be established to show that the duty was breached and caused injury.
There is a cause of "but for" -the failure to meet duty, breach of duty or a deviation of the standard of care. There is a proximate cause - this is- was the injury. seeable. In the legal defense of causation, the most likely to succeed is the proximate cause. Cases can be documented that even though the doctor breached his duty, he didn't cause the injury . The injury could be coincidental due to the health of the patient. . The least likely to succeed is a breach of duty, the "but for". In this case, if it hadn't been for the actions of the doctor ( but for ) the injury would not have occurred.

3. An example of negligent intent would be purposely disclosing personal information, such as a person being HIV positive and giving out the results of a blood test.. An example of intentional disclosure of health information would be in the case of slander or defamation of character. This would be a willful act & one done with the intention to hurt or discredit the other individual. An intentional disclosure could be that a person has a STD and this information was disclosed to purposely discredit the reputation of the plaintiff. In both cases, there must be four elements of negligence present: 1) the defendant owed the plaintiff a duty 2) the defendant breached a duty 3) the plaintiff suffered an injury 4) there is a connection between the breach of duty & the plaintiff's injury.

4. An immunity defense of tort law is one that doesn't deny the wrong doing or that they ( the doctors or corporation or hospital ) deny that liability. This immunity occurs due to the status of the defendant and not necessarily because of the facts. Governments, public officers, charities, parents and children and legal disputes between spouses are barred from tort actions.

5. The statute of limitations defense will require that the case will have to be heard within a certain time frame. The statue of limitations is a statutory enactment - placing restraints or time limits on certain actions or claims. The statue of limitations can vary from state to state. The most general rule is that the time period will begin to run when the act or injury is completed. The statue of limitations can differ if the parties involved in the tort have a contract stating a time period or limitation on the normal or typical time frame of litigations. This must be an contractual agreement between the parties involved..

6. Contract law is an agreement ( contract ) in writing between the parties involved. It typically is between two persons or a corporation. . In the contract, there has to be an offer of agreement, the acceptance of the offer and a consideration. A consideration is what one of the parties will receive from the other in filling the duties or obligations of the contract.
Tort law is involved with the cause or negligence of a party against another party. It also involves things that were intentionally done wrong. There is not an agreement between the parties here.

7. Malpractice insurance crises began in the 1970 - 1980. There was a huge rise in claims. Some of the blame could be attributed to greed or junk claims. The cost of insurance started to rise because of the rise in the number of claims and the amounts paid out from those claims. Now premiums seem to rise yearly. Due to the constant rise in premiums, some doctors have dropped malpractice insurance. Some factors that have contributed to the .rise in the cost is the fact that some doctors choose to not carry insurance, the frequency and severity of the claims adn the fact that insurance companies are dropping coverage.. This drives up the cost for those who do carry insurance. The fact that coverage for insurance has been mismanaged is also a contributing factor. Many believe the insurance companies are playing catch up from previous mismanaged underwriting losses. This is contributing to the much higher cost of insurance.
.
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#808
Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Answers for Chapter 6 Patricia

1. Express consent is the consent that is given through words. These words can either be in writing or spoken. Implied consent is consent that is given through some other means or actions other than words.
Express consent is more legally sound because the agreement for consent for medical treatment is spelled out in words and signed or is spoken, often with the presence of a witness. Express consent is given by the patient. In the case of a minor child, express consent is given by the parent. In the case of a mentally impaired individual or an elderly geriatrics patient, the express consent is given by the guardian or trustee.
Implied consent could be present in an emergency situation. If treatment is needed and the patient is unable to state their own wishes, the medical doctor can use implied consent to treat the patient. That means implying that the patient would normally want to treated.

2. Before undergoing a medical procedure, especially an invasive one, I would want to know the diagnosis, type of treatment and nature and reason for treatment as well as any risks and benefits of the treatment. I would want to know any alternative treatments, even if the insurance didn't cover it. I would also want to know the benefits and risks of this alternative treatment. I would like to know what the possible prognosis would be from not receiving the proposed treatment or procedure.

3. Informed consent isn't required in a criminal case, such as drunk driving. The law also waves consent in cases of mental illness. If the court can provide " good cause " for an exam where the mental or physical condition of a patient is at question, informed consent can be waved. Informed consent isn't required in cases where the parties involved have waved their rights. This could refer to subjects in a research program. The rights could be waved or altered if approved in advance by a review board. The subjects in the study of this type would still be protected under the legal definition of what is called Common Rule. ( this means usually involve minimal risk ) Informed consent is not legally required in the case of therapeutic privilege. This would be the case in which the doctor believes full disclosure of the facts would be harmful, mentally or physically to the patient. This could be problematic in cases of governmental interventions, especially where a person's rights must be waved for the protection and welfare of the general public and society..The government could also order tests suspected in the transmission of disease, such as HIV or an epidemic. In cases like this, the government could order a quarantine or isolation of the public.

4. An advance directive is a legal means for a person to convey their individual healthcare wishes in advance should something happen and they are unable to voice their own opinion. . There is a legal document called a ( POA )- power of attorney. This type of document gives the principal person the right to give a party or parties legal right to act on their behalf to make legal and financial decisions. This only applies if the principal person is mentally competent. The durable power of attorney ( DPOA ) is similar but does allow the persons appointed agent to act with authority if he is incapacitated. This type of document often deals with legal transactions, financial and real estate matters. In healthcare situations, a durable power of attorney for healthcare decisions ( DPOA-HCD ) is often drafted. This gives the principal persons agent the right to act for their rights in medical decisions should they become incapacitated and unable to act on their own. This is also referred to in some states as a medical power of attorney or a healthcare proxy. Obviously all the documents have their own legal validity. The POA is good for limited assistance. The DPOA is better because it covers the condition of incapacitation. The DPOA-HCD is paramount in healthcare issues because it expressly states what your wishes are and how you want your rights to be carried out.. .
The living will is a good tool to be used for protection individuals wishes to refuse or limit treatment, if one becomes incapacitated. It does not necessarily need an appointed agent. It is a signed document and is very good to have to protect you rights.
The DNR - do not resuscitate is a good legal tool to convey a patient's wishes also. If a person is terminally ill, they may wish to have this to protect their rights to speak for them self. This document can be revoked by the patient , if they change their mind. There have been cases where the DNR had been suspended during surgery, but for the most part it is a good document stating the patient or family's rights to not prolong suffering or emotional stress or both.

5. A minor has the legal right to consent to their own medical treatment if they have been declared an emancipated minor by the court. This gives the minor the legal status of an adult. A minor who is married is often considered an adult by the situation alone. In a situation of drug abuse & STDs, a minor has the legal right to consent to their oen medical treatment and the law protects them. The theory is that if treatment is not rendered without parental consent, the minor may not consent to treatment. The untreated minor could then be considered a detriment to society and them self.. The minors should absolutely be permitted , in these cases, to seek medical treatment without parental approval. Many minors may not seek medical help otherwise, fearing that their parents would find out.
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Re:Legal Aspects of Health Care Records 2 Years, 5 Months ago Karma: 0
Martha Soto
Chapter 4 Discussion Questions

1. Health records can provide evidence in a malpractice suit, the record would show what procedures where done and what steps were followed. The information in the record or even missing information can reflect if any wrong doing or negligence occurred.

2. Discoverability is a process of discovery of evidence in a case that happens pretrial. It's the exchange of information between the two parties.

Admissibility is evidence that is allowed to be admitted during trial.

The law distinguishes between the two because some evidence that is discovered in the pretrial process , may not be admissible at trial.

In a medical malpractice negligence case maybe not all the content of the medical record would be admissible. Medical history and procedures not pertaining to the case could be left out.

3. Six ways that the electronic records differ from paper records are.
(1) Volume and Duplicability- What is written electronically is automatically saved and protected against accidental loss of that information. A paper medical record can easily be misplaced or accidentally destroyed.

(2) Persistence- A paper medical record can easily be destroyed, it could be shredded or disposed of in many different ways. When an electronic record is "deleted", it does not mean that the record is actually gone. It could still be stored on the computers hard drive.

(3) Dynamic Changeable Content- An electronic record can easily be altered, or some information can be deleted. But on a paper record any alteration made to the record can be noticed and cannot be hidden.

(4) Metadata- Metadata is information of the record in the system consisting of create/edit dates, authorship, and edit history that could be used to authenticate the record.

(5) Environment-Dependence and Obsolescence- Unlike paper documents if an electronic record is moved from its original place, for example to another computer, that computer has to have the right software to open the record. If not the record will not open correctly or open at all.

(6) Dispersion and Searchability- Electronic records have a "search" or "find" option and every record matching the keywords entered will come up automatically with a paper record, that kind of research would take hours of manual labor.

4. I believe the health information professional would be involved in the process of the e-discovery. Do to the fact that the person that manages and is in charge of the record.

5. The health care provider must produce the health record as they are kept in the regular course of business organize and label the information requested in the demand.

6. The health record is generally an exception of hearsay because the information in the record was altered in the regular course of business, at or near the time of the event. The intended purpose of the record is for the medical care and the authenticity of the record is properly established. Also all statements are made for medical diagnosis or treatment.

7. Patient privilege can be waived when that patient's condition and or treatment need to be reviewed for a court case. Also when a patients blood alcohol test needs to be released at trial for driving while under the influence and also to determine a patients mental capacity in case they need to be committed.

8. An incident report is not in the health record because the purpose of an incident report is to document facts of an incident so that an internal investigation of that incident can be conducted. Incident reports should not be placed or referred to in a patients health record. State law protects incident reports from being admitted into evidence during legal proceedings.
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