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MAINTAIN a legally defensible health record
Assessment Strategies
Oral, written or graphic assessment
Criteria
differentiate between the legal health record and the designated record set
examine record security and integrity concepts
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EXAMINE the processes and legal documents intended to assure patient rights (i.e., Advance Directives, consents, research and IRB process, DNR, etc.)
Assessment Strategies
Oral, written or graphic assessment
Criteria
identify patient’s rights according to regulations and standards
outline procedural steps in the documentation and maintenance of a patient's advanced directive
outline processes to execute a patient's advance directive
identify elements in an informed consent
determine who may consent in given situations
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INTERPRET laws and regulations affecting health information
Assessment Strategies
Oral, written or graphic assessment
Criteria
describe the role of precedent, government and administrative agencies in law making
trace legislation from its inception to its current state
identify sources of law/resources for monitoring changes in legislation and accrediting agency standards
access federal and state legislation and accrediting agency standards that apply to a given situation
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APPLY confidentiality, privacy, and security measures pertaining to the use, access, disclosure and exchange of protected health information
Assessment Strategies
Oral, written or graphic assessment
Criteria
ensure policies address state and federal privacy and security laws
explain concept of medical identify theft and consequences
ensure state and federal privacy and security laws for given situations
comply with HIPAA regulations regarding the patient’s right to access, amend and restrict disclosure of their protected health information
apply access and disclosure policies and procedures
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PROCESS requests for health information
Assessment Strategies
Oral, written or graphic assessment
Criteria
verify that the authorization for disclosure contains required elements
categorize given cases as reportable/nonreportable under mandatory reporting requirements legislation
apply state formula for calculation of copying fees/follow procedures for billing for copies
determine the federal or state law that applies to specific cases
review given cases to determine whether information may be released
follow procedures for processing a request for patient related information
maintain user access logs/systems to track access to and disclosure of identifiable patient data
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PREPARE health information for legal proceedings
Assessment Strategies
Oral, written or graphic assessment
Criteria
determine appropriate court case criteria met for certified copies
verify certification process is complete
update user access logs/systems to track access to and disclosure of identifiable patient data
describe how to notify appropriate personnel
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RECOMMEND response to breach of professional ethics
Assessment Strategies
Oral, written or graphic assessment
Criteria
evaluate the nature of the breach in ethics
provide a recommended response (i.e., disciplinary action, legal action etc.) to the breach in ethics
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ANALYZE policies and procedures to assure departmental and organizational compliance with regulations and standards
Assessment Strategies
Oral, written or graphic assessment
Criteria
discuss the importance of policies and procedures as it relates to regulations and standards
analyze policies and procedures to ensure compliance with regulations and standards
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EXAMINE the organization’s accreditation, licensure and credentialing processes
Assessment Strategies
Oral, written or graphic assessment
Criteria
identify accrediting and licensing requirements and standards
collect data for required monitoring activities
report results of the review in compliance with accreditation/licensing requirements
summarize the credentialing process
outline the medical staff appointment/reappointment process
examine delineation of clinical privileges
examine peer review process
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EVALUATE risk management/patient safety data for patterns, trends and opportunities for improvement
Assessment Strategies
Oral, written or graphic assessment
Criteria
explain the historical development and goals of risk management
outline the risk management structure and process
differentiate between the approaches to risk reduction
investigate methods for risk identification
investigate tools and techniques to manage loss prevention and reduction
draw conclusions based on risk data