American Legal System
This type of law is concerned with an agreement between two or more parties that creates some type of obligation to act (do something) or refrain from acting (not do something) in exchange for some type of consideration
This ethical concept refers to independence, self-determination, or freedom.
What is autonomy?
The legal right to keep certain information confidential and protect it from subpoena, discovery, or introduction into evidence at trial.
What is privilege?
This refers to someone failing to do something that a reasonably prudent person would do in a similar situation or, alternatively, doing something that a reasonably prudent person would not do in a similar situation.
What is negligence?
This document contains a complete and accurate description of a patient’s history, condition, diagnostic and therapeutic treatment, and the results of treatment.
What is a health record?
This branch of government enforces the law.
What is the executive branch?
A form of surgery wherein one body part (tissue or organ) is transferred from one site to another or from one individual to another.
What is organ transplant?
______ is a tool consisting of policies and procedures that address how to respond to legal process requests. This plan should be developed with the advice of the healthcare provider’s legal counsel.
What is a litigation response plan?
“the thing speaks for itself.”
What is res ipsa loquitur?
This HIPAA rule grants rights to patients to amend their health record.
What is the Privacy Rule?
_______ refers to recognition by a professional association that an individual possesses the knowledge, experience, and expertise of the standards set by the professional association.
What is certification?
This ethical theory promotes the greatest balance of good over harm for everyone.
What is utilitarianism?
A subpoena commanding the production of books, documents, and other things. Often used in the context of health information management.
What is a subpoena duces tecum?
Medical abandonment is considered this type of tort.
What is intentional?
These policies are the general principles determining the length of time health data, and the health records in which those data are stored, must be maintained by the health care provider.
What are record retention policies?
This first step of the legal process is a written document that describes the grounds of the jurisdiction of the court, the plaintiff's claim in a short and plain statement, and the demand for relief to which the plaintiff feels entitled.
What is a complaint?
The Hippocratic Oath states in part that a physician will apply "measures to benefit the sick". The ethical concept expressed in this state is ________.
What is beneficence?
This type of requirement requires that the health record be made and kept in the ordinary course of business, at or near the time the event was recorded, and by a person with knowledge of the acts, events, conditions, opinions, or diagnoses appearing in it.
What is trustworthiness requirement?
This statute protects physicians, other rescuers, and private citizens who render emergency care in a nontraditional setting, such as at an automobile accident on the side of the road.
What is the Good Samaritan Statute?
This document shows what data and records were destroyed, who destroyed those data and records, and the method used for that destruction.
What is a COD or certificate of destruction?
______ is a record or catalog showing a sequence of user activity of a computer system, including who accessed what data, when such access occurred, and whether and what changes were made.
What is an audit trail?
Passive euthanasia involves the practice in which no heroic measures are taken to preserve life. This type of passive euthanasia is recognized in the healthcare setting.
What is a DNR or Do Not Resuscitate order?
A health record can be used as ________ to support or discredit a party's claim.
What is evidence?
This law requires a hospital or physician to treat a patient who is in active labor or in an emergency medical condition until the condition is stabilized. Once the condition is stabilized, the hospital and physician have the following three choices: continue to treat the patient, transfer the patient, or, discharge the patient.
What is EMTALA or Emergency Medical Treatment and Active Labor Act?
_______ addresses both electronic records management principles (all of the digital and analog records) and enterprise content management principles (the technology, tools, and methods to capture, store, deliver, and preserve content across an enterprise).
What is ECRM or enterprise content and record management?