Search Results

= Members only

Current search

193 results.

[1] 2

Copy and Paste Run Amok—EHRs and Malpractice

Author: Journal of AHIMA Staff

Source: Journal of AHIMA

Publication Date: September 2016


As if physicians needed another reason to be wary of electronic health records (EHRs), a new study finds that malpractice claims related to EHR use have risen in accordance with increased EHR adoption.


The study, which was conducted by The Doctors Company, a malpractice insurance....

What It Means to Be Deposed

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: July 22, 2016




In this blog I talk about legal consequences. I usually provide current examples of what those consequences might be under a specific set of facts. Here, instead, I want to highlight a litigation-related event that readers might experience in the future—or perhaps already have: a depo....

What Lies Ahead in 2016?

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: December 18, 2015





This is the last Legal e-Speaking post of 2015. I thought I would use it to predict what 2016 might bring in litigation and beyond. When looking ahead to the next year, there are many possible things that HIM professionals should keep an eye out for, but five stand out to m....

Mastering the Inbox Information Era: Patient-Generated Data and Mobile Health are Changing the Management of Health Information

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: September 2015



When Melissa Ziller’s daughter was diagnosed with type 1 diabetes three months before her third birthday, Ziller grappled with all the usual worries that come with the diagnosis. Chief among them was pricking her toddler’s fingers multiple times per day to test her glucose levels. Shortly....

ESI Meets Court Order

Author: Hedges, Ron

Source: AHIMA blog post | Journal of AHIMA - website

Publication Date: June 11, 2015



I’ve written for AHIMA on various subjects, including preservation and spoliation of electronically stored information (ESI). This month, I want to ask you to think about both.


To start, consider this premise: The parties to a civil action agreed to an order “on D....

How to Respond to Subpoena and Discovery Requests

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: November 2014



Health information management (HIM) professionals are frequently pulled into litigation due to their role as custodians of health records and protected health information. This role also can categorize them as parties to civil litigation, which obligates them to produce any relevant infor....

Risks and Results of Data Spoliation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: October 2014



The September e-HIM Best Practices article answered some basic questions about preservation of records in the context of civil litigation. This article will consider the question, “What if something goes wrong?”

Spoliation Defined


Health information management (H....

How and Why to Preserve Health Records During Litigation

Author: Hedges, Ron

Source: Journal of AHIMA

Publication Date: September 2014



The term preservation, when used in a legal context, refers to placing information identified as relevant to a civil or criminal US court case in a legal hold to ensure the data is not destroyed or tampered with.


Health information managers, or anyone who works with records....

How to Prepare the Record for an E-Discovery Request

Author: Kearney, David

Source: Journal of AHIMA

Publication Date: February 2014



At a minimum healthcare organizations should identify the components of their legal health record. The legal health record is a consistent declaration of what patient care information is maintained within an organization and what information would be released during a legal or investigato....

E- Discovery Litigation and Regulatory Investigation Response Planning: Crucial Components of Your Organization’s Information and Data Governance Processes

Author: AHIMA

Source: AHIMA practice brief

Publication Date: November 2013

I. What is E-Discovery?



E-discovery is defined as the pretrial legal process used to describe the method by which parties will obtain and review electronically stored information. The 2006 Federal Rules of Civil Procedure (FRCP) served to place electronically stored information (....

Managing Health Information in Mobile Devices

Author: Washington, Lydia

Source: Journal of AHIMA

Publication Date: July 2012


While the jury is still out on whether mobile devices will eventually replace laptops and PCs, many observers are predicting that their use will continue to explode in the next few years. There are currently at least 10,000 health-related apps that could be downloaded to a mobile electronic de....

Mandates Encourage E-Discovery

Author: AHIMA

Source: Journal of AHIMA

Publication Date: May 2012


Today's US healthcare delivery system is facing an unprecedented sea change, led by federal initiatives that will foster a rise in the number of e-discovery requests hitting HIM departments.

Federal initiatives like the American Recovery and Reinvestment Act, the Patient Protection an....

Creating a Legal Health Record Definition

Author: McLendon, Kelly

Source: Journal of AHIMA

Publication Date: January 2012


As a medical record custodian, it is the HIM professional's responsibility to address legal EHR issues proactively rather than reactively. Defining an organization's legal health record (LHR) in advance will enable an entity to be prepared for both routine and high-stress record requests. Ever....

Privacy and the EHR

Author: Nelson, Debra S

Source: AHIMA Convention

Publication Date: October 02, 2011


Determining how to implement privacy regulations and policies in an electronic record environment can not only be daunting but also thought of quite late in the EHR implementation process. Daily processes and tasks such as reviewing the medical record with patients to processing requests for a....

Legal Considerations in Joining an HIE

Author: Dimick, Chris

Source: Journal of AHIMA

Publication Date: October 2011


The legal issues healthcare organizations must consider when joining a health information exchange (HIE) go far beyond the standard HIPAA-related concerns.

HIEs are rapidly gaining prominence in healthcare, bolstered by federal initiatives like the meaningful use program, which requ....

Amendment, Corrections and Deletions Technical Paper

Author: Wiedemann, Lou Ann

Source: AHIMA Convention

Publication Date: October 02, 2011


The health record is the legal and business record of the healthcare organization. As such, ensuring accurate and timely doucmenation is paramount for information management. The Centers for Medicare and Mediciad services (CMS) has patient safety goals. A key component to this process is to ma....

Managing Physician Queries in the EHR

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: July 2011


Federal incentives provided for the meaningful use program under the American Recovery and Reinvestment Act are encouraging hospitals to adopt electronic health records (EHRs). Eighty percent of hospitals are planning to become meaningful users of EHR technologies in 2011, and the healthcare i....

Patient’s Role in Ensuring Legal EHR Data Integrity

Author: Kohn, Deborah

Source: Journal of AHIMA

Publication Date: May 2011


For nearly 40 years I have served as an HIM and health IT professional, but for my entire life I have been a healthcare patient. My understanding of the processes that create medical records has helped me identify system and human mistakes in my own records. Consequently, I know well that the....

EHRs as the Business and Legal Records of Healthcare Organizations. Appendix A: Issues in Electronic Health Record Management (2010 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


Electronic health record management (EHRM) is the process by which electronic (e.g., digital) health records are created or received and preserved for legal or business purposes. EHRM requires decision making throughout the EHR’s life cycle-through the processing, distribution, maintenanc....

EHRs as the Business and Legal Records of Healthcare Organizations. Appendix B: Checklist for Transition to the EHR (2010 update)

Author: AHIMA

Source: AHIMA practice brief attachment

Publication Date: November 2010


Editor's note: This checklist combines and updates the October 2004 practice brief appendix "The Strategic Importance of Electronic Health Records Management: Checklist for Transition to the EHR" and the June 2005 practice brief "A Checklist for Assessing HIM Department Readiness and Planning f....

EHRs Prove a Difficult Witness in Court

Author: Dimick, Chris

Source: Journal of AHIMA - website

Publication Date: September 2010


Sep 24, 2010

The EHR is a valuable clinical tool for streamlining and improving patient care. But it is complicating and confusing the courts.

As the first cases involving electronic health records make their way into legal proceedings, everyone involved is discovering th....

Deleting Errors in the EHR

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: September 2010



Many types of documentation errors can occur in electronic health records (EHRs), such as incorrectly recording the sex of a patient, documenting in the wrong patient record, and incorrectly identifying the ordering physician on a laboratory report.


It is important to addres....

E-Discovery from the Judicial Perspective

Author: DeLoss, Gerald E.

Source: Journal of AHIMA

Publication Date: July 2010


In a typical legal action, judges have a different perspective on the production of electronically stored information (ESI) than do HIM professionals. The Federal Rules of Civil Procedure, case law, and past experiences with discovery disputes play an important role in how judges view e-discov....

Managing Patient-provided Information in EHRs

Author: Warner, Diana

Source: Journal of AHIMA

Publication Date: July 2010


Ensuring correct and complete patient health information is an ongoing challenge for healthcare organizations. Patient-provided health information can help organizations gain a more complete view of a patient's health, and electronic health records (EHRs) provide multiple tools that allow pati....

Using Clinical Photos in EHRs

Author: Wiedemann, Lou Ann

Source: Journal of AHIMA

Publication Date: April 2010



For most organizations, patient-identifiable source data include data from interpretations, summaries, or notes. These data are usually maintained within the originating department, separate from the HIM department and the health record, and sometimes in a different database. Examples incl....

Still Seeking the Legal EHR: The Push for Electronic Records Increases, the Record Management Questions Remain

Author: Dougherty, Michelle; Washington, Lydia

Source: Journal of AHIMA

Publication Date: February 2010


Electronic health records are edging into the mainstream, but they still have one foot outside the law. Many EHR systems struggle to create credible and compliant business records, and with major initiatives like the ARRA incentive program pushing their adoption, now is the time to get the ele....

Electronic Signature, Attestation, and Authorship. Appendix A: HL7 EHR-System Records Management and Evidentiary Support (RM-ES) Functional Profile Standard Excerpt (2009 update)

Author: AHIMA e-HIM Work Group: Best Practices for Electronic Signature and Attestation

Source: AHIMA practice brief attachment

Publication Date: November 2009


The records management and evidentiary support functional profile standard is a subset of functions and conformance criteria from the HL7 EHR-S Functional Model standard. The standard was created specifically to address requirements and criteria for basic record management functionality in EHR....

Sequestering EHR Data in IT Systems

Author: Miaoulis, William M

Source: Journal of AHIMA

Publication Date: May 2009


There can be three situations under which healthcare organizations may need to sequester (or segregate) certain data within a medical record: placing a legal hold in connection with litigation, limiting disclosures of a record pursuant to a request by a patient, and restricting access to sensi....

Authenticating EHR Metadata

Author: McLean, Thomas R

Source: Journal of AHIMA

Publication Date: February 2009


Any medical malpractice action involving electronic records is likely to raise issues concerning metadata. Metadata are tantamount to an audit trail of how an electronic record was used and modified.

However, before this audit trail can be used in court, it must be authenticated. Whi....

Leading on the Legal EHR

Author: Hicks, Jewelle E

Source: Journal of AHIMA

Publication Date: January 2009


Carol F. Smith, MBA, RHIA, is enthusiastic about the year ahead. As director of health information management for the University of Texas Anderson Cancer Center in Houston, TX, Smith supervises 110 full-time employees and works on projects ranging from revenue cycle, data quality, medical reco....

Releasing Records from Other Providers

Author: Herrin, Barry S.

Source: Journal of AHIMA

Publication Date: November 2008


Question: Should organizations include records of other providers when responding to a release of information?

Answer: Yes. There are three reasons this is so.

First, there is no law or regulation that generally prohibits the redisclosure of information received from anot....

When is the PHR the EHR?

Author: Beach, Joan

Source: AHIMA Convention

Publication Date: October 17, 2008

Introduction

Are you ready to tackle the use of the Personal Health Record (PHR) and its integration into the Legal Health Record? Be prepared to find the point of integration and how to use the information provided by the patient. Learn how the “proxy” relationship impacts th....

HIM Professional's Role in Enterprise Content Management : Stepping Out of the Department and Into the Organization

Author: May, Michael L.; Martinez, Christina M.

Source: AHIMA Convention

Publication Date: October 17, 2008


Background


HIM Professionals can re-assert themselves as integral pieces of the EHR decision-making process for their organization by gaining new operationally appropriate technical competencies and building collaborative partnerships with our IT, clinical informatics, and leaders....

Applying Legal Holds to Electronic Records

Author: Nunn, Sandra L.

Source: Journal of AHIMA

Publication Date: October 2008


Historically, applying a legal hold has been a straightforward process for the HIM professional in charge of release of information. When a record consisted of a file folder whose content was a structured set of paper documents, sequestering a medical record was as simple as pulling and outgui....

[1] 2