A health information legal and regulatory terminology

Chapter 9
At the end of this chapter, the student should be able to:
• Define key terms
• Identify and define health information legal and regulatory terminology
• Maintain the patient record in the normal course of business
• Maintain confidentiality of protected health information (PHI)
• Comply with HIPAA privacy and security provisions
• Interpret legislation that impacts health information management
• Appropriatly release protected health information
Whatsoever things I see or hear concerning the life of men, in my attendance on the sick or even apart therefrom, which ought not be noised abroad, I will keep silence thereon, counting such things to be as sacred secrets. Oath of Hippocrates, 4th century, BC
This chapter discusses legal aspects of health information management (HIM) covered as part of an introductory course in health care academic programs such as coding and reimbursement, health information administration, health information technology, medical assistant, medical billing, medical office administration, medical secretary, medical transcription, and so on. For comprehensive coverage (e.g., taught as a separate course), refer to Cengage Learning’s Legal and Ethical Aspects of Health Information Management, 4th edition, by Dana C. McWay.
The following topics are covered in this chapter: legal and regulatory terminology Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security issues, release of information processing, reportable conditions and events, and the use of specialized health information (e.g., HIV). Additional information about HIPAA can be found in Cengage Learning’s HIPAA for Health Care Professionals, by Carole Krager and Dan Krager. The following legal aspects of HIM are discussed elsewhere in this textbook:
• Chapter 1: Ethics
• Chapter 2: Accreditation, regulation, and physician credentialing
• Chapter 4: Amending record entries, authentication of record entries, computer-based patient record (CPR), destruction of records, facility closure (e.g., handling patient records), incident reports, legibility of record entries, ownership of the patient record, patient record completion responsibilities, potentially compensable event (PCE), provider documentation requirements (e.g., amending the record, correcting errors), record retention laws, and timeliness of record entries
• Chapter 6: Advanced directives, consent forms, content of the patient record (e.g., The Joint Commission standards, Medicare conditions of participation), and informed consent
• Chapter 7: Security of patient information
• Chapter 10: Health care reimbursement legislation