What role do accreditors and federal and state agencies play in regulating healthcare facilities?
The custodian of the legal health record is responsible for the control, care, access, release, certification, maintenance, and disposal of the health record contents. The custodian’s role is generally composed of multiple personnel from multiple departments, with HIM professionals handling the operational functions such as protecting, collecting, and archiving the legal health record.
When a health record becomes involved in the U.S. legal process due to some form of litigation, the custodian must oversee the authentication, admissibility, and disclosure of the information it contains. In order to effectively govern the health record and comply with relevant legal regulations, the custodian should be knowledgeable of the U.S. legal system, including federal and state agencies, rules of evidence, and torts and consents.
Imagine you are the HIM manager at a large hospital, and your institution is being sued for a pattern of malpractice. Create an outline of the key details regarding the U.S. legal system and health record legal process that HIM student interns in your department should know as they prepare to disclose health record information or admit contents as evidence. Be sure to propose key guidelines on how to certify health records that are requested for litigation, and address the following topics:
• How is the U.S. legal system structured?
• What are the different types of laws?
• How are torts and consents impacted in healthcare?
• What role do accreditors and federal and state agencies play in regulating healthcare facilities?
• What are the Federal Rules of Evidence and Uniform Rules of Evidence?
• What is the legal health record?
• Who is the custodian of the health record?
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