Title: Discoverability and Admissibility of Medical Records
Course: HIM 2012 Health Law > Section: Module 2 - Discoverability and Admissibility of Medical Records

Introduction

Patient information is routinely relevant in legal proceedings.  Health information professionals are charged with the responsibility of protecting health information must often act as the gatekeeper for appropriate disclosure of information in legal proceedings.  An understanding of  state and federal laws as well as the legal processes where in health records are requested and used as evidence during litigation is necessary.

Health information evidence presented at trial is usually obtained through the pre-trial discovery process.  Discoverability refers to the limitations on the ability of parties to discover pretrial information held by another.  Discovery involves a pretrial exchange of information between parties via depositions, interrogatories, physical exams and mental exams, and so on.

Admissibility refers to evidence that is allowed to be admitted in a court of law.  Evidence that is discoverable during the pretrial period may not necessarily be admissible at trial.  As a general rule, only relevant evidence is admissible at trial.

Objectives

Upon completion of this module, the student will be able to
- Distinguish discoverability and admissibility
- Describe and apply the hearsay rule
- Explain the principle of patient-provider privilege
- Explain the business records exception and other exceptions to the hearsay rule
- Explain why health records generally constitute hearsay

Readings & Resources

Required:  Brodnik, Melanie.  Fundamentals of Law for Health Informatics and Information Management.  AHIMA Press.  Current edition. (Chapters 3 & 4)

Optional:  Pozgar, George.  Legal Aspects of Health Care Administration.  Jones and Bartlett Learning.  Current edition.  (Chapter 6)
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. 3 and Chp. 4 in the Brodnik text

- Take the Module 2 Quiz
- Post on the Module 2 Discussion Board
- Post the Module 2 Internet Activity
- Continue working on the Health Law Electronic Portfolio (due in Module 10)