Title: Documentation and Disclosure: Special Concerns
Course: HIM 2012 Health Law > Section: Module 9 - Documentation and Disclosure: Special Concerns

Introduction

In general, the HIPAA Privacy Rule provides that no Protected Health Information is to be used or disclosed without authorization unless the Privacy Rule provides an exception to the authorization requirement.    The Privacy Rule permits disclosure without authorization, however it does not compel or require such disclosure.  There are several federal regulations that require reporting to appropriate authorities any deaths of serious occurrences related to patients who have been restrained or placed in seclusion.  The Conditions of Participation regarding patient who have been restrained or placed in seclusion rights to all Medicare and Medicaid participating hospitals.   These regulations apply to the following types of facilities: short term, psychiatric, rehabilitation, long term, children’s and alcohol and drug abuse facilities.

Common reporting requirements mandated by state laws may include abuse and neglect of children, the elderly, and the disabled, communicable diseases, suspicious or unattended deaths, vital statistics and registries.  Common federal mandatory and voluntary reporting systems related to Medicare and Medicaid programs include quality measures, medical devices, registries and national health statistics.

Objectives

Upon completion of this module, the student will be able to:Discuss federal and voluntary reporting requirements that do not require patient authorization
- Describe the purpose of maintaining clinical, disease and outcome-based registries
- Discuss state reporting requirements related to abortion, birth defects, reportable deaths, wounds, worker’s compensation and unusual events

Readings & Resources

Required reading:  Brodnik, Melanie.  Fundamentals of Law for Health Informatics and Information Management.  AHIMA Press.  Current edition. (Chapter 13)

Optional:  Pozgar, George.  Legal Aspects of Health Care Administration.  Jones and Bartlett Learning.  Current edition.  (Chapter 11)
Optional:  Servais, C.  The Legal Health Record.  AHIMA Press. Current edition
American Society of Law, Medicine and Ethics
American Health Information Management Association
Agency for Healthcare Research and Quality
Healthcare Information and Management Systems Society
American Medical Informatics Association

Assignments and Activities

- Read Chp. 13 in the Brodnik text

- Take the Module 9 Quiz
- Post on the Module 9 Discussion Board
- Post the Module 9 Internet Activity
- Continue working on the Health Law Electronic Portfolio (due in Module 10)