Legal Procedures of Healthcare

• Discuss the process that legal proceedings follow
• Name the steps of a legal proceeding from complaint to verdict
• Differentiate between a subpoena, a subpoena duces tecum and a court order
• Delineate the steps to follow to secure a health record once a subpoena has been received
• Describe how to respond to a court order with the subpoenaed record
• Discuss the relationship between the Health Information Department and the Risk Management Department in medicolegal cases

Course outcome assessed/addressed in this Assignment

• HI135-2: Explain legal terminology used by health information professionals.

Instruction

There are two options for the Assignment in Unit 3. Choose one of the following case studies and the associated Assignment.  Be sure to explain legal terminology used by health professionals in the case you choose. Submit your Assignment to the appropriate Dropbox.

Case 1: 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 for Mary Smith, as required in your state. How should you respond to the subpoena? Use Chapter 3 of your McWay textbook as a resource and write a script of the discussion you would have with the attorney presenting the invalid subpoena and authorization.  In the script, explain the information that is required to be able to release Ms. Smith’s records. You are an HIM professional, so you will certainly want your dialogue to reflect your professionalism; however he has not provided adequate documentation so help him understand what he needs to provide.

Case 2: You are a health information manager closely involved with risk management at General Hospital, a teaching hospital.  Beginning this July, the hospital will incorporate presentations by hospital employees into its grand rounds lectures.  You have been asked to present the lecture covering risk management. Compose a presentation addressing the legal aspects of risk management, particularly concentrating on patient record requirements and incident reports. Use Chapter 12 of your McWay textbook as a resource and create a short power point presentation showing how a properly documented health record reduces risk to a healthcare facility. You may also show how health information professionals and risk management professionals work together to improve documentation in the healthcare record.

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