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HIT 211 - Medicolegal Aspects in Health Information Management

1. Apply healthcare legal terminology, legal concepts and principles to the practice of HIM
2. Identify the use of legal documents, potential abuse or fraudulent trends through data analysis
3. Apply retention and destruction policies for health information to data storage and retrieval
4. Interpret legal requirements to ensure compliance with local, state, and federal labor regulations
5. Comply with ethical standards of practice

1. Describe basic laws, legal system, requirements, patient rights, legal vocabulary, which govern health care.
2. Describe court systems, legal procedures, regulatory requirements, and agencies which relate to health care professionals, occupations, and facilities, including licensure and accreditation and the role of the health information manager within those processes.
3. Identify legal guidelines related to liability, documentation, authenticating, and correcting the medical record.
4. Apply federal, state, and legal guidelines to patient medical record and other health care situations, including legislative processes, statutes and regulations governing retention of health records and health information to ensure compliance.
5. Explain policies and procedures to ensure patient confidentiality with regard to appropriate authorizations and consents to include release of information, particularly with respect to Health Insurance Portability and Accountability Act (HIPAA).
6. Explain informed consent and the institutional policies and procedures to protect electronic health information (EMR-electronic medical record).
7. Explain the judicial process affecting health information management within the medical and legal fields, including advance directives.
8. Identify and explain the application of current legislation, standards, and security of specialized patient records.
9. Explain risk management and quality management including quantitative and qualitative analyses of health records to evaluate compliance and how to ensure facility-wide compliance.
10. Discuss standards, procedures, and confidentiality regarding HIV information.
11. Explain liability issues with computerized patient records (EMRs)
12. Explain health care fraud and abuse.
13. Discuss ethics and explain policies to ensure ethical practices.

1. American Legal System
   1. Public and private Law
   2. Sources of law
   3. Branches of government
   4. Quasi-legal requirements
   5. Patient rights
2. Court Systems and Legal Procedures
   1. Court systems
   2. Legal process
   3. Alternative dispute resolutions
3. Principles of Liability
   1. Healthcare relationships
   2. Theories of liability
   3. Defenses and limitations on liability
4. Patient Record Requirements
   1. Function and use of the medical record
   2. Legal requirements for the medical record content
   3. Retention requirements
   4. Record destruction
5. Access to Health Information
   1. Ownership of health information
   2. Notice of use and disclosure
   3. Access by or on behalf of the patient
6. Patient Rights and Confidentiality
   1. Patient rights          
   2. Confidentiality
   3. Informed consent
   4. Release of information
7. Judicial Process of Health Information
   1. Medical records as evidence
   2. Responses to legal process
   3. Advance directives
8. Specialized Patient Records
   1. Drug and alcohol abuse
   2. Mental health and developmental disability care
   3. Home health care
   4. Genetic information
9. Risk Management and Quality Management
   1. Risk management
   2. Quality management
   3. Quantitative and qualitative analyses
10. HIV Information
    1. Testing
    2. Patient confidentiality
    3. Legal challenges
11. Computerized Patient Records
    1. Accreditation and licensure issues
    2. Liability issues
    3. Electronic health record issues
12. Health Care Fraud and Abuse
    1. Fraud and abuse
    2. Compliance programs
13. Ethics
    1. Medical ethics
    2. Policies and ethical guidelines 

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