Competency 730.3.1: Legislative and Legal Systems – The graduate applies common procedural and conceptual aspects of the law relating to health information management in situations that arise within healthcare organizations. Competency 730.3.2: Laws, Regulations, and Standards for Health Information/Informatics – The graduate evaluates management policies and practices for legal health records and recognizes consequences for healthcare organizations when records are used to substantiate healthcare law.
Health informatics professionals are required to know the laws and regulations that impact health information management. At some point in your career, you may be asked to participate in policy review or development and apply specifications included in new regulations to existing policies. You should understand how new regulations impact the healthcare organization and how best to educate staff on any changes.
This task will provide you with the “Sections of Montana Code” needed for one portion of this assessment. The codes include definitions from Montana law pertaining to the validity of consent of minor for health services (41-1-402), confidentiality of health information (50-16-603), patients’ examination and copying (50-16-541 and 50-16-542), and reasonable fees allowed (50-16-540).
A. Discuss the various issues that should be considered by a healthcare organization when defining the legal health record.
B. Discuss one situation from Montana Code 41-1-402 (2a–d) that may result in criminal liability to the organization if not followed, using HIPAA’s definition of criminal liability.
C. Discuss one situation from Montana Code 50-16-603x (1–7) specific to health record identification that may result in a legal claim against the organization if not followed.
D. Compare three points in the Montana codes to HIPAA laws as they refer to release of information.
E. When you use sources, include all in-text citations and references in APA format.
Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section.
Note: When using sources to support ideas and elements in an assessment, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the assessment.
Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section.
1. Health Record Policies Health Record Policies:
You work in a health information management department for an outpatient clinic. Your manager is revising the policy and procedural manuals for the department and is particularly interested in confirming that policies are in compliance with state law and Health Insurance Portability and Accountability Act (HIPAA) Privacy Law. Your manager asked you to review several policies and to review state code as they apply to HIPAA Law.
Your manager left the following two policies on your desk for review:
Release of Information: Shadow Chart Policy
“A shadow chart is a duplicate health record kept for the convenience of the medical provider. In the event that an authorized individual requests health information pertaining to a specific episode of care, health information management staff will review any shadow charts kept by medical providers for that patient to determine if any such shadow charts contain information related to the episode of care. If the shadow chart contains information related to the episode of care and is not found in the electronic record, the information from the shadow chart will also be copied, in addition to requested information found in the electronic record.”
Your supervisor left a note that this policy needs an addendum.
Information Security: Workstation Policy
“Employees are required to secure their personal workstations when not in use. Confidential health information must not be displayed on computer screens unless the employee is performing work functions on the computer and using the information. Employees may not access another employee’s computer while it is in use nor may employees use another’s password for any reason. Violation of this policy will result in disciplinary action, and depending upon nature of violation, termination may result.”
You now move on to review several documents containing Montana Code and draft policy language. The Montana Code documents pertain to release of information, protected health information of minors, and health information confidentiality.
2. Sections of Montana Code: SUBJECT: Information Security: Release of Information
50-16-541. Requirements and procedures for patient’s examination and copying. (1) Upon receipt of a written request from a patient to examine or copy all or part of the patient’s recorded health care information, a health care provider, as promptly as required under the circumstances but no later than 10 days after receiving the request, shall: (a) make the information available to the patient for examination, without charge, during regular business hours or provide a copy, if requested, to the patient; (b) inform the patient if the information does not exist or cannot be found; (c) if the health care provider does not maintain a record of the information, inform the patient and provide the name and address, if known, of the health care provider who maintains the record; (d) if the information is in use or unusual circumstances have delayed handling the request, inform the patient and specify in writing the reasons for the delay and the earliest date, not later than 21 days after receiving the request, when the information will be available for examination or copying or when the request will be otherwise disposed of; or (e) deny the request in whole or in part under 50-16-542 and inform the patient. (2) Upon request, the health care provider shall provide an explanation of any code or abbreviation used in the health care information. If a record of the particular health care information requested is not maintained by the health care provider in the requested form, the health care provider is not required to create a new record or reformulate an existing record to make the information available in the requested form. The health care provider may charge a reasonable fee for each request, not to exceed the fee provided for in 50-16-540, for providing the health care information and is not required to provide copies until the fee is paid. History: En. Sec. 13, Ch. 632, L. 1987; amd. Sec. 5, Ch. 300, L. 1999. 50-16-540. Reasonable fees allowed. A reasonable fee for providing health care information may not exceed 50 cents for each page for a paper copy or photocopy. A reasonable fee may include an administrative fee that may not exceed $15 for searching and handling recorded health care information. History: En. Sec. 1, Ch. 300, L. 1999. 50-16-542. Denial of examination and copying. (1) A health care provider may deny access to health care information by a patient if the health care provider reasonably concludes that: (a) knowledge of the health care information would be injurious to the health of the patient; (b) knowledge of the health care information could reasonably be expected to lead to the patient’s identification of an individual who provided the information in confidence and under circumstances in which confidentiality was appropriate; (c) knowledge of the health care information could reasonably be expected to cause danger to the life or safety of any individual; (d) the health care information is data, that is compiled and used solely for utilization review, peer review, medical ethics review, quality assurance, or quality improvement; (e) the health care information might contain information protected from disclosure. (f) the health care provider obtained the information from a person other than the patient; or (g) access to the health care information is otherwise prohibited by law. (2) A health care provider may deny access to health care information by a patient who is a minor if: (a) the patient is committed to a mental health facility; or (b) the patient’s parents or guardian has not authorized the health care provider to disclose the patient’s health care information. (3) If a health care provider denies a request for examination and copying under this section, the provider, to the extent possible, shall segregate health care information for which access has been denied under subsection (1) from information for which access cannot be denied and permit the patient to examine or copy the information subject to disclosure. (4) If a health care provider denies a patient’s request for examination and copying, in whole or in part, under subsection (1)(a) or (1)(c), the provider shall permit examination and copying of the record by the patient’s spouse, adult child, or parent or guardian or by another health care provider who is providing health care services to the patient for the same condition as the health care provider denying the request. The health care provider denying the request shall inform the patient of the patient’s right to select another health care provider under this subsection. History: En. Sec. 14, Ch. 632, L. 1987; amd. Sec. 6, Ch. 657, L. 1989; amd. Sec. 19, Ch. 515, L. 1995; amd. Sec. 6, Ch. 359, L. 2001.
BAT Task 1 (0314)
Articulation of Response (clarity, organization, mechanics) The candidate provides adequate articulation of response. A. Legal Health Record The candidate provides a logical discussion, with sufficient detail, of the various issues to be considered by a healthcare organization when defining the legal health record.
B. Criminal Liability The candidate does not provide a logical discussion of 1 situation from Montana Code 41-1-402 (2a–d) that may result in criminal liability to the organization if not followed, using HIPAA’s definition of criminal liability. The candidate provides a logical discussion, with sufficient detail, of 1 situation from Montana Code 41-1-402 (2a–d) that may result in criminal liability to the organization if not followed, using HIPAA’s definition of criminal liability.
C. Health Record Identification : The candidate provides a logical discussion, with sufficient detail, of 1 situation from Montana Code 50-16-603x (1–7) specific to health record identification that may result in a legal claim against the organization if not followed.
D. Comparison of Montana Codes: The candidate provides a logical comparison of 3 points in the Montana codes to HIPAA laws as they refer to release of information.
E. Sources :When the candidate uses sources, the candidate provides appropriate in-text citations and references accurately or with only minor deviations from APA style.
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