The judicial process of health information and some principles of liability.

Our chapters this week examine the judicial process of health information and some principles of liability.  Many times, staff handle routine release of information tasks and the subpoenas and court orders will be handled by senior or lead staff or a supervisor or manager.   A manager or director may also be designated as the custodian of records and may need to occasionally appear in court with records and state, under oath, that they were made in the regular course of business.  The custodian of records would not testify regarding the clinical documentation itself; only that the documentation procedures were followed.

In recent years, the federal rules of civil procedure were updated to allow for e-discovery of electronic records and most states have been updating their state rules of civil procedures as well.  The health information manager needs to be familiar with the rules of civil procedure section on the handling of subpoenas and court orders at both the federal and state level.

There may be state law specific to certain care settings that the health information manager needs to be familiar with.  For example, when I was the statewide medical records manager for the Oregon Department of Corrections, state law did not allow us to respond to subpoenas.  We needed a release signed by the inmate or former inmate or a court order.  If I received a subpoena, I would call the attorney’s office and quote the OAR number and most of the time they had a signed release already on file that they could send me.

In addition, the court order needs to be from a court of competent jurisdiction, meaning the court must have the authority to enforce it.  This means that you typically do not have to respond to a court order from an out-of-state court.

I hope you learn a lot this week.