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Medical Records and the Law, Fourth Edition

Author(s): William H. Roach Jr., MS, JD
Details:
  • ISBN-13: 9780763734459
  • ISBN-10:0763734454
  • Hardcover    591 pages      © 2006
Price: $217.95 US List
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Instructor Resources: Instructor's Manual, PowerPoints

 

NEW! This title is now available as a set with Ethical Challenges in the Management of Health Information. Perfect for your courses dealing with both the law and the ethics of health information management. Contact your publisher's representative to learn more.

 

Published in conjunction with the American Health Information Management Association (AHIMA), Medical Records and the Law provides the tools healthcare providers and government agents need, given the increased focus on accountability for the quality of health care. This timely revision features new information on topics such as the growth of electronic health record systems and electronic data networks; state laws affecting the use and disclosure of health information; the highly complex interplay of federal and state health information privacy laws; and the challenging subject of how patient information may be used in connection with medical research involving human subjects.

 

Features:

  • Addresses the voluminous privacy, security, identifier, code set, and transactions regulations.
  • Provides the tools healthcare providers and government agents need, given the increased focus on accountability for the quality of health care.
  • Focuses on the reduction of errors and rapid access to electronic health records as an essential and fundamental part of successful quality improvement efforts.

 

Chapter 1 Introduction to the American Legal System

  • The Nature of Law
  • Sources of Law
  • Governmental Organization and Function
  • Organization of the Court System

Chapter 2 Medical Records and Managed Care

  • Utilization Review
  • Managed Care
  • Managed Care Organizations and Related Entities
  • The Impact of Managed Care on Health Information
  • Management
  • HIPAA and State Privacy Rules
  • Changes in Medical Records Standards

Chapter 3 Medical Records Requirements

  • Records That Must Be Kept
  • The Legal Health Record
  • Content Requirements
  • Record Retention Requirements
  • Destruction of the Record

Chapter 4 Medical Records Entries

  • Legible and Complete Medical Records Entries
  • Timely Medical Records Entries
  • Authorship and Countersignatures
  • Authentication of Records
  • Verbal Orders
  • Corrections and Alterations

Chapter 5 Document Consent to Treatment

  • Legal Theories of Consent
  • Distinguishing Informed Consent and HIPAA Authorization
  • Who Can Give Consent
  • Responsibility for Obtaining Consent
  • Documentation
  • Types of Consent Forms

Chapter 6 Access to Health Information

  • Types of Health Information
  • Ownership of the Medical Record
  • Summary of Confidentiality Requirements
  • HIPAA Covered Entities
  • Exercise of Professional Judgment
  • Minimum Necessary Rule
  • Hybrid Entities, Affiliated Covered Entities, and Organized Healthcare Arrangements
  • Uses and Disclosures of Medical Records Information
  • Record Duplication and Fees
  • QIO Record Keeping
  • Business Associates
  • Additional Patient Rights Under HIPAA
  • Verifying Identity and Representations
  • HIPAA Administrative Requirements

Chapter 7 Reporting and Disclosure Requirements

  • Disclosures Required by Law
  • Other Health Related Reporting Requirements

Chapter 8 Documentation and Disclosure: Special Areas of Concern

Chapter 9 HIV/AIDS: Mandatory Reporting and Confidentiality

  • Duty to Report
  • Protecting Confidentiality of HIV-Related Information
  • Statutory Provisions Regarding Disclosure
  • Liability for Unauthorized Disclosure of HIV-Related Information
  • Recommended Policies and Procedures

Chapter 10 Discovery and Admissibility of Medical Records

  • Discoverability of Medical Records
  • Admissibility of Medical Records
  • Other Healthcare Documentation

Chapter 11 Legal Theories in Improper Disclosure Cases

  • HIPAA Liability
  • Other Statutory Bases for Liability
  • Theories of Liability

Chapter 12 Risk Management and Quality Management

  • Increased Scrutiny of Medical Errors and Demand for
  • Improving Quality Care
  • Relationship Between Risk Management and Quality Management
  • Risk Management
  • Quality Management
  • HIPAA and Risk Management/Quality Management
  • Compliance Programs
  • Medical Records in Risk Management,Quality Review, Compliance Activities, and Pay for Performance Initiatives

Chapter 13 Electronic Health Records

  • The Movement to Electronic Health Records
  • HIPAA Privacy Rule
  • HIPAA Security Rule
  • State Data Security Laws
  • Regulatory Issues
  • Electronic Health Records as Evidence
  • Professional Liability
  • Specific Electronic Health Records Security Issues

Chapter 14 Health Information in Medical Research

  • U.S. Federal Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
  • State Laws Relating to Acquisition and Use of Health Information in Connection with Medical Research
  • International Laws Relating to Medical Records and Clinical Trials
  • Other Guidance
  • Conclusion

Appendix A Glossary: Acronyms and Definitions

Index


William H. Roach Jr., MS, JD

William H. Roach, Jr., is a partner in the Chicago office of McDermott Will & Emery LLP based in the firm’s Chicago office. Mr. Roach’s experience includes the formation of regional and national hospital systems; mergers, acquisitions, affiliations, and dispositions of healthcare facilities and systems; joint sponsorship of faith-based healthcare facilities and systems; corporate reorganizations; hospital/ physician integration arrangements; health industry joint ventures; creation and implementation of corporate compliance plans; focused compliance reviews; tax-exempt organizations; and medical staff organization, credentialing, and contracts. He has served as in-house general counsel of two large academic medical centers, and he has also represented institutions of higher education in matters relating to governance, student records, joint ventures, and faculty organization. Mr. Roach is a member of the editorial advisory boards of numerous professional journals, including Briefings on HIPAA and Medical Records Briefing, and a contributing editor of the Hospital Law Manual. Mr. Roach is recognized for his experience in the law governing the use of healthcare information and regularly advises healthcare providers, ancillary service providers, and manufacturers concerning HIPAA compliance matters. He received his J.D. from Vanderbilt University Law School, his M.S. from the University of Pittsburgh, and his A.B. from Columbia University.

 

Robert G.Hoban is counsel in the Chicago office of McDermott Will & Emery LLP. He was previously general counsel to a major suburban Chicago healthcare system, where he also served as its chief planning officer. Since 1975, Mr. Hoban has served as borrower’s counsel for more than $1.5 billion of tax-exempt bond financing transactions for hospitals throughout the country, and has served as counsel in connection with hospital restructurings and mergers, revision of corporate and medical staff bylaws, and negotiations of unified medical staff bylaws. He has assisted clients in the development of hospital-physician joint ventures, structuring hospital risk management programs, establishment of physician practice management entities, and other aspects of corporate hospital organization. Mr. Hoban has established ambulatory surgery centers and has acted as a consultant to physicians with regard to practice mergers. He also has experience with the formation of HMOs,PHOs, MSOs, and IPAs; and the construction, financing, and leasing of medical office buildings and imaging centers.Mr. Hoban has also presented seminars on medical staff credentialing, the liability aspects of risk management programs, discharge planning, release of medical records, and the legal concerns of palliative medicine. He received his J.D. from Northwestern University School of Law and his B.A. from Yale University.

 

Bernadette M. Broccolo is a partner in the Chicago office of McDermott Will & Emery LLP and has been advising health industry organizations for 25 years on legal and regulatory compliance matters, information technology acquisition, and health information privacy. Her general health practice includes federal taxation of exempt organizations, corporate governance and restructurings, hospital-physician relationships, and clinical research compliance counseling. Ms. Broccolo’s health information technology practice includes drafting and negotiating agreements for the development and acquisition of healthcare information and telecommunication systems. She also advises health clients on the complex legal considerations involved in the electronic exchange, and other uses and disclosures, of health information, including the requirements imposed by HIPAA and other privacy and confidentiality laws. She is currently serving on the HIPAA Task Force appointed by the governor of the state of Illinois to focus on HIPAA preemption and other state law implications of HIPAA compliance. Ms. Broccolo currently serves as a member of the Governing Council of the American Bar Association’s Health Law Section, and is the immediate past chair of the Health Law Section’s Tax & Accounting Interest Group. She received her J.D. from the Notre Dame Law School, and her B.S. from Boston College.

 

Andrew B. Roth is the partner-in-charge of the New York health law practice of McDermott Will & Emery, LLP. Mr. Roth represents health industry clients on transactional and regulatory matters, including healthcare networks, integrated delivery systems, hospitals, managed care companies, physicians, and others. His practice extends to many medical/legal areas, including mergers and acquisitions, fraud and abuse, corporate compliance, and long-term healthcare facility representation. Mr.

  • "This is an excellent book and a valuable reference for anyone requiring a solid understanding of the legal aspects of medical records and health information.

    This edition addresses the requirements for protecting health information in the Health Insurance Portability and Accountability Act (HIPAA) and the growth of electronic health record systems and their unique challenges in protecting health information. I wholeheartedly recommend this book to instructors in health information legal courses and to health information practitioners to have as a reference for the perplexing questions that arise on a regular basis concerning the legal aspects of the health records they manage."

    —Doody's Book Review Service, October 2008, Doody's Weighted Numerical Score: 90 - 4 Stars!

  • "...an excellent book and a valuable reference for anyone requiring a solid understanding of the legal aspects of medical records and health information. This edition addresses HIPAA requirements and the growth of electronic health record systems and their unique challenges in protecting health information. I wholeheartedly recommend this book to instructors in health information legal courses..."

    —LouAnn Schraffenberger, MBA, RHIA, CCS, CCS-P, Univ. of Illinois at Chicago (For Doody's Book Review Service)

The following instructor resources are available to qualified instructors for download

ISBN-13: 9780763734459

Instructor Manual
Slides in PowerPoint Format