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MAINTAIN a legally defensible health record
Assessment Strategies
Oral, written or graphic assessment
Criteria
you differentiate between the legal health record and the designated record set
you 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
you identify patient’s rights according to regulations and standards
you outline procedural steps in the documentation and maintenance of a patient's advanced directive
you outline processes to execute a patient's advance directive
you identify elements in an informed consent
you 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
you state the function and membership of the legislative, executive and judicial branches of the US government
you describe the role of precedent, government and administrative agencies in law making
you trace legislation from its inception to its current state
you identify sources of law/resources for monitoring changes in legislation and accrediting agency standards
you 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
you ensure policies address state and federal privacy and security laws
you explain concept of medical identify theft and consequences
you ensure state and federal privacy and security laws for given situations
you comply with HIPAA regulations regarding the patient’s right to access, amend and restrict disclosure of their protected health information
you apply access and disclosure policies and procedures
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PROCESS requests for health information
Assessment Strategies
Oral, written or graphic assessment
Criteria
you verify that the authorization for disclosure contains required elements
you categorize given cases as reportable/nonreportable under mandatory reporting requirements legislation
you apply state formula for calculation of copying fees/follow procedures for billing for copies
you determine the federal or state law that applies to specific cases
you review given cases to determine whether information may be released
you follow procedures for processing a request for patient related information
you 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
you determine appropriate court case criteria met for certified copies
you verify certification process is complete
you update user access logs/systems to track access to and disclosure of identifiable patient data
you 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
you evaluate the nature of the breach in ethics
you provide a recommended response (i.e. disciplinary action, legal action etc.) to the breach in ethics