You supervise the correspondence unit of the health information serv.pdf

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You supervise the correspondence unit of the health information services department of a medical center. Today, you received a subpoena duces tecum from an attorney, demanding either the originals or copies of all health records concerning Mary Smith, who allegedly is or was a patient of the medical center. The subpoena lacks sufficient information for you to determine whether Mary Smith is or was a patient in your facility. The subpoena is not accompanied by a valid authorization to release information for Mary Smith, as required in your state. How should you respond to the subpoena? TEXTBOOK: Legal and Ethical Aspects of Health Information Management by McWay 4th edition. Solution A subpoena refers to a document issued by the court or a call to appear in court. It is court- ordered rule that basically requires you to do something, such as give evidence or present information that may help support the details that are at issue in a pending case. By the following way respond to the subpoena-.

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Week#4-To Do List-CCH Introduction To Consent and Documentation Documentation of patient consent to provide care, to disclose (or not disclose) information and other issues provide the necessary proof of compliance. Objectives To successfully complete this learning unit, you will be expected to: Determine situations where consent is required. Identify each type of written consent. Determine the qualifications for a compliance officer. Set internal policies for acquiring patient consent. Establish a process to handle release of information. Week 4: Discussion Answer the following questions 1. Discuss the importance of the idea that everyone should complete an advance directive 2. Discuss the issue of super confidentiality Week 4: Case Study Assignment Include a response to the following case study: Case study on page 75 of your textbook. (This is the first case study in the chapter and is titled "Chapter Case Study." It starts with: “Calls to Blue Cross Blue Shield Michigan’s (BCBSM) Anti-Fraud Hotline led to an . . .") Your paper must address the following: Address problem of the case decision A thorough analysis including resources Detailed comprehensive realistic recommendation Supplements with extensive compelling evidence from legitimate sources Sources cited correctly in the body of the case and reference page Chapter Case Study “July 28, 2003: A physician from Minneapolis, MN, agreed to pay $53,400 to resolve his liability under the CMP [Civil Monetary Penalties] provision applicable to violations of a provider’s assignment agreement. By accepting assignment for all covered services, a participating provider agrees that he or she will not collect from Medicare beneficiary more than applicable deductible and coinsurance for covered services.” “The OIG alleged that the physician created a program whereby the physician’s patients were asked to sign a yearly contract and pay a yearly fee for services that the physician characterized as ‘not covered’ by Medicare. The OIG further alleged that because at least some of the services described in the contract were actually covered and reimbursable by Medicare, each contract presented to the Medicare patients constituted a request for payment other than the coinsurance and applicable deductible for covered services. In violation of these terms of the physician’s assignment agreement. In addition to payment of the settlement amount, the physician agreed not to request similar payments from beneficiaries in the future.” (http://www.oig.hhs.gov) Essentials of Health Care Compliance Week Three Compliance: Patient Consent Learning Outcomes Identify the various situations in which consent is required Determine the components of each type of written consent form Explain the types of advance directives Establish internal policies for acquiring patient consent Design a process to handle release of information The single biggest probl.

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Is health information always admissible as evidence in court? Explain your answer and provide APA references. Solution What is one of the most important non-clinical uses of the medical redcord? It serves as the legal document recording a particular episode of a patient\'s care. (of the facility and treatment) When can a patient\'s information be disclosed? With the written consent or authorization of the patient. pursuant to statutory requirements or on proper legal process. Define Evidence Testimony, writings, material objects, or other things presented to prove or disprove a fact. Define ADMISSIBLE EVIDENCE Info. or things that may be admitted as evidence in a trial if the applicable rules establish that the info. is BOTH PERTINENT and PROPER (timely, accurate, complete records) for the the judge or jury to consider when deciding issues involved in the lawsuit. What is HEARSAY? Out-of-court statements that are offered to prove the truth of the matter asserted. Not signed under oath. Why are medical records considered hearsay evidence? Because the health-care providers making the statements, (entries into the record) do not do so under oath in a court of law. Therefore under the Hearsay rule they are not admissible as evidence in court. So, if Hearsay evidence is not addmisible in court, how can medical records be an exception to the rule? There ARE exceptions to the rule... BUSINESS RECORD EXCEPTION to the HEARSAY EXEMPTION RULE specifically allows medical records to be used as evidence. if the person offering the records can successfully convince the judge the records are kept in the ordinary course of business and not in preparation for litigation. BUSINESS RECORD EXCEPTION to the HEARSAY EXEMPTION RULE HIM Mgr. / Custodian must establish in court the FOUNDATION and TRUSTWORTHINESS of their record-keeping. The three elements of a FOUNDATION REQUIREMENT to the hearsay exemption? Person submitting the evidence must extablish that the record was; 1. Made and kept in the ordinary course of business 2. recorded at or near the time the event 3. By a person with knowledge of the facts, events, conditions, opinions, or diagnoses appearing in it. How is TRUSTWORTHINESS REQUIREMENT to the hearsay exception established? One of the requirements of the Business Record Exemption to the hearsay rule. HIM/custodian must testify to: - Internal policies/procedures governing access to meddical record - quality control techniques (i.e. corrections & abbreviations of the record) How does the party wishing to introduce a medical record as evidence establish the accuracy and trustworthiness of the medical record? They will bring in the custodian of medical records to testify to the accuracy and trustworthiness of the records. How does the Medical Records Custodian testify as to both the foundation and trustworthiness requirements of the business record exception? The custodian, the HIM professional, testifies in a trial or deposition: - To FOUNDATION - testifi.

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Are You Following the Script? Consequences for Medical Professionals Who Fail to Check Pharmacy Registries As the problem of prescription drug addiction has grown, states have responded with the creation of prescription registries controlled by pharmacy boards. Anyone prescribing medications (specifically doctors, physician assistants and nurse practitioners) is required to check these registries before prescribing certain drugs, but this step is often missed. If discovered, failure to closely monitor your patient could result in discipline up to the loss of your license to practice medicine.

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