Chapter 2 - Legal Issues In Health Information Management Flashcards
Acceptance
In contract law, requires a meeting of the minds between the parties about terms that are sufficiently definite and complete.
Accreditation
- A voluntary process of institutional or organizational review in which a quasiindependent body created this purpose periodically evaluates the quality of the entity’s work against pre-established written criteria.
- A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards.
- The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency.
Acquittal
Lack of proven guilt.
Adhesion contract
A contract provision that places a healthcare provider in a significant position of power over a patient who relies on the provider’s services may be against public policy.
Administrative law
A body of rules and regulations developed by various administrative entities empowered by congress; falls under the umbrella of public law
Administrative system
System that controls governmental administrative operations and operates through federal and state administrative agencies that enact regulations
Advance directive
A legal, written document that describes the patients preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences.
Answer
Response prepared by the defendant or attorney on the defendants behalf.
Apology statute
Also known as “ I’m Sorry” laws, these statutes protect a healthcare providers apology from being admitted into evidence during a court proceeding as an admission of liability.
Appellate court
Courts that hear appeals on final judgment of the state trial courts or federal trial courts.
Arbitration
A proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system.
Arm’s length transaction
A transaction in which parties are dealing from equal bargaining positions, neither party is subject to the others control or dominate influences, and the transaction is treated with fairness, integrity, and legality.
Arraign
To call before the court.
Assault
A deliberate threat, along with apparent ability, to cause contact with another person that either can either be offensive or cause physical harm.
Assumption of risk
The plaintiff who voluntary places himself or herself at risk to a known or appreciated danger may not recover damages for injury resulting from the risk.
Authentication
- The process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials or electronic signature.
- Proof of authorship that ensures, as mush as possible, that log-ins and messages from a user originate from an authorized source.
- As amended by HITECH, means the corroboration that a person is the one claimed.
Authenticity
The genuineness of a record, that it is what it purports to be; information is authentic if proven to be immune from tampering and corruption.
Battery
The intentional and nonconsensual touching of another person
Breach of Warranty
A broken promise where the plaintiff must show there was an express or implied warranty.
Burden of proof
- A legal term that obligates an individual to prove or disprove a fact. Normally belongs to the plaintiff in a civil suit. 2. Under HITECH, a covered entity or business associate, as applicable, shall have the burden of demonstrating that all notifications were made as required by this subpart or that the use or disclosure did not constitute a breach, as defined at 164.402.
Charitable immunity
A doctrine that shielded hospitals ( as well as other institutions) from liability for negligence because of the belief that donors would not make contributions to hospitals if they thought their donations would be used to litigate claims combined with concern that a few lawsuits could bankrupt a hospital
Circuit
Geographic area covered by the US Court of Appeals.
Circuit court
One of 13 federal appellate courts
Civil law
The branch of law involving court actions among private parties, corporations, government bodies, or other organizations, typically for the recovery of private rights with compensation usually being monetary.
Common law
Unwritten law originating from court decisions where no applicable statute exists.
Comparative negligence
The plaintiff’s conduct contributed in part to the injury the plaintiff suffered, but the plaintiff’s recovery is reduced by some amount based on his or her percentage of negligence.
Complaint
In litigation, a written legal statement from a plaintiff that initiates a civil lawsuit.
Consent
A unique unit of knowledge or thought created by a unique combination of characteristics
Consideration
- Refers to attention to the interpersonal aspects of work, including respecting subordinates’ ideas and feelings, maintaining harmonious work relationships, collaborating in teamwork, and showing concern for the subordinates’ welfare. 2. A contract must be supported by legal and bargained-for consideration, which is what parties will receive from each other in exchange for performing the obligations of the contract.
Contract
- A legally enforceable agreement. 2. An agreement between a union and an employer that spells out details of the relationship of management and the employees.
Contract law
A branch of law based on common law that deals with written or oral agreements that are enforceable through the legal system.
Contributory negligence
The plaintiff’s conduct contributed in part to the injury the plaintiff suffered and, if found to be sufficient, can preclude the plaintiff’s recovery from injury
Corporate negligence
A doctrine in which hospitals may be held liable in their own right.
Counterclaims
In a court of law, a countersuit.
Criminal law
A branch of law that addresses crime that are wrongful acts against public health, safety, and welfare, usually punishable by imprisonment or fine.
Criminal negligence
An individual may be found liable if his or her behavior is categorized as reckless disregard or deliberate indifference.
Cross-claim
- In law, a complaint filed against a codefendant. 2. A claim by one party against another party who is on the same side of the main litigation.
Defamation of character
A false communication about someone to a person other than the subject that tends to injure that person’s reputation.
Default judgment
A court ruling against against a defendant in lawsuit who fails to answer a summons for court appearance.
Defendant
In civil cases, an individual or entity against whom a civil complaint has been filed; in criminal cases, an individual who has been accused of a crime.
Deposition
A method of gathering information to be used in a litigation process.
Designated record set (DRS)
As amended by HITECH: 1. A group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered heath provider; (ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by for or for a heath plan; or (iii) Used, in whole or part, by or for the covered entity to make decisions about individuals. 2. For purpose of this paragraph, the term means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity.
District court
The lowest tier in the federal court system, which hears cases involving felonies and misdemeanors that fall under federal statute and suits in which a citizen of one state sues a citizen of another state.
Diversity jurisdiction
Legal matters belonging only to federal courts where the parties do not live in the same state.
Do-Not-Resuscitate Order (DNR)
An order written by the treating physician stating that in the event the patient suffers cardiac or pulmonary arrest, cardiopulmonary resuscitation should not be attempted.
Durable Power of Attorney for Healthcare Decisions
A power of attorney that remains in effect even after the principal is incapacitated; some are drafted so that they only take effect when the principal becomes incapacitated.
e-discovery
Refers to Amendments to Federal Rules of Civil Procedure and Uniform Rules Regulating to Discovery of Electronically Stored Information; wherein audit trails, the source code of the program metadata, and any other electronic information that is not typically considered the legal health record is subject to motion for compulsory discovery.
Electronic health record (EHR)
An electronic record of healthrelated information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
Evidence
The means by which the facts of a case are proved or disproved.
Express Warranty
The seller makes specific promises to the buyer.
False imprisonment
Intentional tort in healthcare where excessive force is used to restrain a patient.
Federal Register
The daily publication of the US Government Printing Office that reports all changes in regulations and federally mandated standards, including HCPCS and ICD-10-CM codes.
Felony
A serious crime such as murder, larceny, rape or assault for which punishment is usually severe.
Fraud
The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).
Freedom of Information Act (FOIA)
The federal law established in 1967, amended in 1986, that I applicable only to federal agencies, through which individuals can seek access to information without the authorization of the person to whom the information applies (Public Law 99-570 1986).
General consent
Permits healthcare providers to perform overall medical care, from a patient for routine treatment.
General jurisdiction
Courts that hear more serious criminal cases or civil cases that involve large amounts of money; may hear all matters of state law except for those cases that must be heard in courts of special jurisdiction.
Good Samaritan Statutes
State law or statute that protects healthcare providers from liability for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident
Governmental immunity
Precludes anyone from bringing a lawsuit against a governmental entity unless that entity consents to the lawsuit.
Grand jury
Has the authority to issue subpoenas for its investigative process, and all evidence considered by the grand jury remains confidential unless an indictment is returned.
Gross negligence
An extreme departure from the ordinary standard or care; it represents reckless disregard.
Health Insurance Portability and Accountability Act (HIPAA)
The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for pre-existing medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employees regardless of size; requires covered entities (most healthcare providers and organizations) to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifiers In HIPAA transactions (Public Law 104-191 1996).
Hung jury
Occurs when members of a jury cannot agree on the defendant’s guilt or lack of proven guilt.
Implied warranty
Exists when the law implies such a warranty exists “as a matter of public policy” to protect the public from harm.
Incident
An occurrence in a medical facility that is inconsistent with accepted standards of care.
Incident report
A quality or performance management tool used to collect data and information about potentially compensable events (events that may result in death or serious injury).
Indictment
Formal charge; needed for a felony crime to be prosecuted.
Infliction of emotional distress
A person can be held liable for the intentional or reckless mental suffering resulting from such things as despair, shame, grief, and public humiliation.
Informed consent
- A legal term referring to a patient’s right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed. 2. An individual’s voluntary agreement to participate in research or to undergo a diagnostic, therapeutic, or preventive medical procedure.
Intent
An individual committed an act purposely of knowing that harm would likely occur.
Interrogatories
Discovery devices consisting of a set of written questions given to a party, witness, or other person who has information needed in a legal case.
Invasion of privacy
The intrusion upon one’s solitude.
Joinder
Codefendant where the defendant brings a claim against an outsider.
Judicial system
The court system where a person or entity has the opportunity to bring a civil action against another person or entity believed to have caused harm.
Jurisdiction
The power and authority of a court to hear, interpret, and apply the law to and decide specific types of cases.
Legal health record (LHR)
Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information.
Legal hold
A communication issued because of current or anticipated litigation, audit, government investigation, or other such matters that suspend the normal disposition or processing of records. Legal holds can encompass business procedures affecting active data, including, but not limited to, backup tape recycling. The specific communication to business or IT organizations may also be called a “hold,” “preservation order,” “suspension order,” “freeze notice,” “hold order,” or “hold notice”.
Legal system
A process through which members of society settle dispute.
Legislative system
Systems that enacts laws and controls many activities related to industry, including the healthcare industry.
Libel
Written form of defamation
Licensure
The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals).
Limited jurisdiction
Lower-level trial courts may only hear certain types of cases and include courts such as probate, family, juvenile, surrogate, and criminal.
Litigation
A civil lawsuit or contest in court.
Living will
A legal document, also known as a medical directive, that states a patients wishes regarding life support in certain circumstances, usually when death is imminent.
Malfeasance
A wrong or improper act.
Mediation
Occurs when cases are heard by a mediator and the parties involved reach a mutual agreement.
Medical Identity theft
The inappropriate or unauthorized misrepresentation of another’s identity to do one of two things: obtain medical services or goods, or falsify claims for medical services in an attempt to obtain money.
Metadata
Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data: for example, creation date, date sent, date received, last access date, last modification date.
Misdemeanor
A crime that is less serious than a felony.
Misfeasance
Relating to negligence or improper performance during an otherwise correct act.
Motion for summary judgment
A request made by the defendant in a civil case to have the case ruled in his or her favor based on the assertion that the plaintiff has no genuine issue to be tried.
Negligence
A legal term that refers to the result of an action by an individual who does not act the way a reasonably prudent person would act under the same circumstances.
Nonfeasance
A type of negligence meaning failure to act.
Offer
One party promises to either do something or to not do something if the other party agrees to either do something or to not do something.
Ordinary negligence
Failure to do what a reasonably prudent person would do, or doing something that a reasonably prudent person would not do, in the same or a similar situation.
Original jurisdiction
State civil and criminal cases are initiated in the lower-level trial courts, which have the authority to first hear a case on a given matter.
Patient Self-Determination Act
The federal legislation, passed through an amendment to the Omnibus Budget Reconciliation Act of 1990 that requires healthcare facilities to provide written information on the patient’s right to issue advance directives and to accept or refuse medical treatment.
Persuasive authority
Though a precedent in one state does not bind courts in other states, states may use each other’s precedents as guidance in analyzing a specific legal problem.
Petition for writ of certiorari
A request for the US Supreme Court to consider a case.
Physician-patient privilege
The legal protection from confidential communications between physicians and patients related to diagnosis and treatment being disclosed during civil and some misdemeanor.
Plaintiff
The group or person who initiates a civil lawsuit.
Potentially compensable event
An event (for example, an injury, accident, or medical error) that may result in financial liability for a healthcare organization, for example, an injury, accident, or medical error.
Precedent
Binding force for future cases addressing the same issues in the state.
Preemption
In law, the principle that a statute at one level supersedes or is applied over the same or similar statute at a lower level (for example, the federal HIPAA privacy provisions trump the same or similar law except when state law is more stringent).
Privacy Act of 1974
A law that requires federal agencies to safeguard personally identifiable records and provides individuals with certain privacy rights (Public Law 93-579 1974).
Private law
The collective rules and principles that define the rights and duties of people and private businesses.
Privilege
The professional relationship between patients and specific groups of caregivers that affects the patient’s health record and its contents as evidence; the services or procedures, based on training and experience, that an individual physician is qualified to perform; a right granted to user, program, or process that allows access to certain files or data in a system.
Prosecutor
An attorney who prosecutes a defendant accused of a crime on behalf of a local, state, or federal government.
Protected health Information (PHI)
As amended by HITECH, individually identifiable health information: 1. Except as provided in paragraph two of this definition, that is: (i) transmitted by electronic media; (ii) maintained in electronic media; or (iii) transmitted or maintained in any other form or medium. 2. Protected health information excludes individually identifiable health information: (i) in education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g(a)(4)(B)(iv); (iii) in employment records held by a covered entity in its role as employer; and (iv) regarding a person who has been deceased for more than 50 years (45 CFR 160.103 2013)
Public law
A type of legislation that involves the government and its relations with individuals and business organizations.
Punitive damages
Damages awarded to punish or deter wrongful conduct over and above compensation for injury.
Regulations
A rule established by an administrative agency of government. The difference between a statute and a regulation is regulations must be followed by any healthcare organization participating in the related program. Administrative agencies are responsible for implementing and managing the programs instituted by state and federal statutes.
Request for production
A discovery device used to compel another party to produce documents and other items or evidence important to a lawsuit.
Respondent superior
“Let the master answer”; liability of employers for any job-related acts of their employees or agents.
Restitution
The act of returning something to its rightful owner, of making good or giving something equivalent for any loss, damage, or injury.
Right to privacy
The right “to be let alone”; this includes the rights of individuals to be free from surveillance and interference, as well as the right to keep one’s information from being disclosed.
Settlement
Official agreements made out of court before going to trial or any time during trial.
Slander
International destruction, mutilation, alteration, or concealment of evidence.
Spoliation
International destruction, mutilation, alteration, or concealment of evidence.
Standard of care
An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines; codes of ethics published by professional associations or societies; regulations for accreditation published by accreditation agencies; usual and common practice of equivalent clinicians or organizations in a geographical region.
Stare decisis
“Let the decision stand”- principle that states that in cases in a lower court involving a fact pattern similar to that in a higher court within the court system, the lower court is bound to apply the decision of the higher court.
Statute of limitations
A specific time frame allowed by a statute or law for bringing litigation.
Statues
A piece of legislation written and approved by a state or federal legislature and then signed into law by the state’s governor or the president.
Statutory (legislative) law
Written law established by federal and state legislatures.
Strict liability
Occurs when a person or entity is held for acts or omissions regardless of whether there was fault.
Subject matter jurisdiction
Legal matters that include federal crimes, such as racketeering and bank robbery.
Subpoena
A command to appear at a certain time and place to give testimony on a certain matter.
Summons
An instrument used to begin a civil action or special proceeding and is a means of acquiring jurisdiction over a party.
Supreme court
The highest court in the US legal system; hears cases from the US Courts of Appeals and the highest state courts when federal statutes, treaties, or the US Constitution is involved.
Tort
An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm.
Trial court
The lowest tier of state court, usually divided into two courts: the court of limited jurisdiction, which hears cases pertaining to a particular subject matters of lower dollar amounts; and the court of general jurisdiction, which hears more serious criminal cases or civil cases that involve large amounts of money.
Trier of fact
Judge or Jury
Writs
Legal written commands
