Legal and Ethical Considerations - Task 1

Shadow charts should only contain copies of the original records. Shadow charts are maintained to assist ancillary departments in treating patients. An original record is created after each treatment for the primary record and a copy can be made for the shadow chart only for convenience in providing care. Original records are not to be kept in shadow charts.

The new user policy section has been modified to require manager approval and validation of the user’s access request based upon the user’s role. Previously the policy only required manager approval for user’s requiring administrator privileges. In accordance with Health Insurance Portability and Accountability Act (HIPAA) standards on access controls, users will have the minimum access required to perform the functions of their job in order to protect against unnecessary access to electronic protected health information (ePHI).

Physical safeguards is the implementation of policies and procedures to limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed which Disposal and Media Re-Use, areas mandatory to be addressed. Technical safeguards includes the implementation of policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons or software programs that have been granted access rights. Requirements include: Unique user identification, Emergency Access Procedures amongst other recommended areas for compliance. I would seek and review these policies to ensure the organization is being compliant. Noncompliance in this area could be detrimental for both the organization and for the patients serviced. If PHI is breached at the organization and there is no established procedure that would ensure corrective action immediately, HHS could impose hefty fines, patients may be notified and could file complaints as well.

B. HIPAA Security Rule The HIPAA Security Rule (HSR) establishes the requirements for security and allows the organization that is implementing new technology to choose the mechanisms they would like to implement to ensure security. The Rule focuses on ePHI or electronic protected health information. The HSR has four requirements: 1. Confidentiality, Integrity, and Availability must be ensured in the data produced, obtained, maintained and transmitted 2. Provide protection against unauthorized use and release of information should be established 3.

The Health Insurance Portability and Accountability Act (HIPAA) is a set of national standards created for the protection of health information; it is also known as a “Privacy Rule”. This rule was employed in 1996 by the US Department of Health and Human Services (DHHS) to address the use and disclosure of an individual’s health information as well as the standards for the individual’s privacy rights to understand and control the manner in which their information is used.

Shadow charts were developed to gather data and information for additional departments and medical personnel that need access to part of a patient’s file or records. The original records should always remain in the patient’s primary chart allow copies may be available to ancillary departments that may need access to the information. The same level of confidentiality and security applies to the shadow charts. They must be in a secure location with access by authorized personnel only. Additional information that should be included in shadow charts is a formal recording process to document those who access the information. Furthermore, a consistent system of upgrading the

HIPAA is governed by 2 entities, the Privacy Rule and the Security Rule. These two rules dictates to outline what the Health and Human Services (HHS) requires to handle Protected Health Information (PHI) in all forms. The Office of Civil Rights (OCR) enforces HIPAA and can leverage

HIPAA, signed into law in 1996, addresses various healthcare issues including insurance coverages, tax-related provisions and group health insurance requirements. HIPPA includes the Privacy Rule which establishes national standards to safeguard patient’s protected healthcare information (“PHI”) including medical records and gives patients access to their health information. These standards apply to health plans, health care clearinghouses and providers who manage healthcare transactions electronically including pharmacists and pharmacy staff.

HIPAA, the federal Health Insurance Portability and Accountability act was signed into law in 1996 by President Clinton. The regulation

Any patient that is seen by a physician within the United States is to be protected by the “Health Insurance Portability and Accountability Act” or HIPAA, which was passed into law in 1996 (Jani, 2009). All health care facilities dealing with any protected health information (PHI) are to ensure that all physical/electronic processes are safeguarded from any third party entity or unauthorized personnel according to HIPAA. All health care data to include any medical insurance

HIPAA is the Health insurance Portability and Accountability Act. It became law in 1996. The original intent was to help employees change jobs and keep their health insurance by making their coverage portable. Later, on April 14, 2003 lawmakers broadened the law to include the Privacy Rule. Protected Health Information(PHI) is a HIPAA term, it includes all medical information of an individual. All patients health information is protected no matter what form it is in. PHI can be controlled in many forms such as backup disk or tapes, insurance statements, lab reports, prescription forms, patient form, email, etc. Five steps to comply with the Privacy Rule are:

Regulation placed upon the healthcare system only seek to improve safety and security of the patients we care for. The enactment of the Health Insurance Portability and Accountability Act (HIPPA) and the enactment of Meaningful Use Act the United States government has set strict regulations on the security of health information and has allotted for stricter penalties for non-compliance. The advancement of electronic health record (EHR) systems has brought greater fluidity and compliance with healthcare but has also brought greater security risk of protected information. In order to ensure compliance with government standards organizations must adapt

The HIPAA Security Rule standards specify a series of administrative, physical and technical security requirements to ensure the confidentiality of electronic protected health information (e-PHI) that is accessed, processed, used or transmitted. These standards are divided into either required or addressable implementation specifications and provide the framework for Topaz to measure compliance. The Risk Management Team performed the following actions to determine compliance with each HIPAA Rule.

The privacy rule applies to personal health information in any form, electronic or paper, which includes the entire medical record. Individuals have full access to their information, can limit who can gain access to his or her records, can request changes to their medical record if there’s any reason they suspect that the information isn't accurate. In addition, the private information shared is kept to the minimal amount needed. Also, the patients have the privilege to decide whether or not to release their protected health information or PHI for purposes unrelated to any treatments or payment issues, such as research project. (Krager & Krager, 2008) HIPAA implemented specific code sets for diagnosis and procedures to be used in all transactions. Covered entities must adhere to the content and format requirements of each standard. (Center for Medicare and Medicaid Services, n.d)The security rule supplements the privacy rule; it deals specifically with electronic PHI or ePHI. It applies to covered entities that transmit health information in electronically. The Security Rule requires covered entities to keep appropriate

Protected health information (PHI) is information in a medical record or set of medical data that can be used to identify an individual and was created during the normal healthcare process (1). Medical identity theft is the use of PHI to obtain medical care, drugs, or submit claims to insurance in another person’s name (2). To help prevent medical identity theft, the Health Insurance Portability & Accountability Act (HIPAA) was passed in 1996 with the purpose of directing how patient is used and can be made available. HIPAA is typically divided into 2 rules: the privacy rule and the security rule. The Privacy rule establishes the standards to protect individual healthcare data and applies to health plans, clearinghouses, and healthcare providers that conduct certain electronic healthcare