CLASS 1

Introduction to medical records law, class materials and course requirements.

Lecture: Chapter 1 – Introduction to the American Legal System

Objectives:     

·         Distinguish between private and public law, civil and criminal law, and tort and contract actions.

·         Discuss how federal constitution delineates governmental authority.

·         Discuss the concept of the rights encompassed by the constitutional right to privacy.

·         Explain what happens when local, state, and federal law overlap.

·         Give examples of administrative agencies, describing their source of authority and how they regulate the public.

·         Name the three branches of government and discuss the responsibilities of each.

·         Distinguish between trial courts, appeals courts, and supreme courts.

·         Explain the relationship between state and federal courts.

CLASS 2

Lecture:  Chapter 2 – Medical Records and Managed Care.

Objectives:     

·         Identify characteristics of managed care industry that have changed the nature of patient records.  

·         Define utilization review and utilization review organizations.

·         Explain the role of patient information in the area of utilization review.

Internet Assignment

Objectives:

·         Explore the research information available on the Internet

·         Explain the use of Internet information in the legal setting

·         View examples of state and federal law sites

·         View examples of judicial, administrative and legislative information available

·         Become familiar with the Internet and its legal research options

CLASS 3

Lecture:  Chapter 3 – Medical Record Requirements. 

Objectives:     

·         Identify the governmental and private entities that establish medical records requirements.

·         Lists the types of information contained in a patient record.

·         Explain why it is important for a record to be complete and accurate.

·         Give examples of the information state law requires in a medical record.

·         Discuss the role of HCFA with regard to medical record content and retention.

·         List sources of law governing medical record retention, and examples of state law requirements.

·         Define statute of limitations and discuss how a statute of limitations affects record retention practices.

·         Explain how medical research and storage space impact on medical record retention.

·         Recommend considerations for medical record destruction policy.

CLASS 4

Lecture:  Chapter 4 – Medical Record Entries.  Review for Exam 1.

Objectives:

·         Illustrate how legibility and accuracy are important to the quality of medical records.

·         Explain how inaccurate, incomplete or illegible entries can impact patient services, claims review and reimbursement for services.

·         Discuss state standards that govern the completeness, accuracy and legibility of medical records.

·         Define what timeliness means with respect to medical record entries and the consequences of failing to comply with this standard.

·         Distinguish between authorship and countersignatures of medical record entries.

·         Explain why authentication is a key element of medical record security and what standards apply to how and when records are authenticated.

·         Define auto-authentication and recommend safeguards for auto-authentication systems.

·         Discuss verbal orders entries and appropriate policies.

CLASS 5

Exam 1.  Library Assignment.  Students utilize the LCCC library Internet facilities.  Students are to answer legal research questions using the Internet resources following the guidelines set out in Class 2.

CLASS 6

Review of Internet legal research assignment. 

Chapter 6 -  Access to Medical Record Information.

Objectives:

·         Explain the general rule regarding ownership of medical record information.

·         Give examples of state laws that protect the confidentiality of medical record information.

·         Describe the types of medical record information protected by federal law.

·         Summarize the rights of patients and third parties to access medical record information,

·         including sensitive information such as alcohol, drug abuse and psychiatric patient records.

·         Give examples of laws governing the release of patient information for medical research.

·         Describe the authority allowing health care providers to charge record duplication fees.

·         Discuss state record duplication fee law.

CLASS 7

Lecture:  Chapter 6 – Access to Medical Record Information.

Objectives:  See Class 5 Objectives.

Use of LCCC Computer Lab.  Explore Internet legal resources.

Objectives:  See Class 2 Objectives.

CLASS 8

Lecture:  Chapter 7, Reporting and Disclosure and Requirements. 

Objectives:

·         Give examples of mandatory reporting laws.

·         Discuss the persons or facilities subject to reporting requirement under mandatory disclosure laws.

·         Give examples of information that must be included in mandatory disclosure reports.

Lecture:  Chapter 9, HIV/AIDS:  Mandatory Reporting and Confidentiality.

Objectives:     

·         Outline statutory requirements for mandatory reporting of HIV/AIDS cases to state and local health departments.

·         Describe restrictions contained in provisions of state HIV/AIDS statutes intended to protect the confidentiality of HIV/AIDS information.

·         Discuss common exceptions specified in state HIV/AIDS statutes prohibiting disclosure of HIV test results without subject’s written informed consent.

·         Explain the limits on disclosure of HIV/AIDS test results of the patient and of the health care provider.

·         Describe statutory provisions allowing disclosure of HIV/AIDS information pursuant to a court order, and gives examples of how courts respond to such requests.

·         Describe liability provisions.

·         Recommend steps to protect patient privacy and confidentiality of HIV/AIDS information.

CLASS 9

Lecture:  Chapter 8, Documentation and Disclosure. 

Objectives:     

·         Discuss state statutes, accreditation standards, and the Emergency Medical Treatment and Active

·         Labor Act requirements pertaining to the content of emergency department records.

·         Discuss documentation and disclosure concerns associated with celebrities, hostile patients,

·         possible child abuse victims, and adoption records.

·         Evaluate the documentation requirements and related obligations placed on health care providers

·         by the Patient Self-Determination Act.

·         Review state power of attorney and advance directive laws.

·         Explain the difference between living wills and durable power of attorney for health care laws.

Submit Workbook project; Review for Exam

CLASS 10

Exam 2; Lecture:  Chapter 5, Documenting Consent to Treatment.

Objectives:     

·         Distinguish between express and implied consent.

·         Identify the information that must be disclosed for informed consent.

·         Discuss what a patient must show in a consent case.

·         Describe the emergency exception to the informed consent requirement.

·         Define the therapeutic privilege and waiver of consent.

·         Identify who can give consent.

·         Discuss the effect of refusal of consent.

·         Discuss the application of informed consent to minors.

·         Distinguish between emancipated minor and mature minor.

·         Compare responsibility for obtaining consent among physicians, providers, facilities, and organizations.

·         Understand informed consent and the importance of documentation..

·         Discuss the impact of religious conviction in refusal to treatment for adults and minors.

·         Distinguish between the different types of consent forms and their uses.

·         Discuss how and when consent may be withdrawn.

CLASS 11

Lecture:  Chapter 5, Documenting Consent to Treatment.  Objectives:  See Class 10 Objectives.

CLASS 12

Lecture:  Chapter 10, Discovery and Admissibility of Medical Records.

Objectives:     

·         Distinguish between discoverability and admissibility.

·         Define the physician-patient privilege and discuss its effect on discovery and admissibility.

·         Describe the health care provider’s role in protecting health information from discovery.

·         Explain waiver of the physician-patient privilege and how the privilege may be waived.

·         Define hearsay.

·         Define business record exception to the hearsay rule and its application to medical records.

·         List other types of information that may be sought in discovery.

CLASS 13

Submit Workbook Project; Lecture:  Chapter 11, Legal Theories in Improper Disclosure. 

Objectives:     

• Describe how state statutes affect liability for releasing medical record information.

• List the elements of a defamation claim and describe when releasing patient information might constitute defamation.

• Discuss the privileges against liability for releasing patient information.

• Describe the effect of a patient's consent to release information.

• Distinguish between a defamation claim and an invasion of privacy claim.

• Lists the types of invasion of privacy claims and give examples in the health information field.

• Discuss the potential liability for publishing patient photographs, releasing patient information to obtain reimbursement, and divulging patient information to the news media.

• Examine the elements of a breach of confidentiality claim.

Lecture:  Chapter 12, Risk Management and Quality Review.

Objectives:     

• Compare and contrast risk management and quality review.

• Discuss the use of medical record information in risk management and quality review areas.

CLASS 14

Lecture:  Chapter 13, Computerized Medical Records.

Objectives: 

• Distinguish between a fully computerized patient record system, a fully automated computer-based patient record, and computer-based records.

• Discuss the benefits of computerized patient records.

• Explain the legal concerns that arise from computerization of patient records.

• Identify the sources of law that govern confidentiality of computerized health information. 

• Explain why security is important to a computerized medical record system, examples of safe-guards against unauthorized access, including technological, physical and user access controls.

• Discuss the concerns associated with outside users of computerized medical record information.

• Clarify how durability and accuracy requirements apply to computerized patient records.

• Discuss admission of computerized medical records into evidence.

• List methods of protecting the security of faxed and e-mailed medical information.

• Discuss the process of e-mail and the use of the Internet in conveying patient information.

• Discuss the confidentiality problems with relaying patient health information over the Internet.

Review for Exam.

CLASS 15

Exam 3.