Hi 135 Unit 9 Assignment: Complying With Laws And Regulation

Hi 135 Unit 9 Assignment Complying With Laws And Regulations In The

Verify that documentation in the health record supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status. A 45-year-old female has requested a copy of her 80-year-old father's health record. She has presented Power of Attorney (POA) and has a legal right to access his records. You provide a copy to the woman, but she has many questions regarding documentation of her father's diagnosis. He was admitted to the ICU last week from the skilled nursing facility. When discharged, he was transferred to a Long-Term Care Hospital (LTCH). In a brief written response to the woman, relate the components of the health record that support diagnosis and reflect the patient's progress, clinical findings, and discharge status. Explain the documentation used for these purposes within skilled nursing facilities, ICU, and LTCH.

Validate data from secondary sources to include in the patient's record, including personal health records. As the Director of Health Information for a large teaching hospital, there are many students completing clinical rotations at your facility. There have been recent concerns that some students are not following appropriate use of the Electronic Health Record (EHR), which has compromised several patient records. Additionally, a glitch is present in the new patient and physician portals, which allows patients to enter data into their own records while physicians cannot enter data. In an executive summary, justify your rationale for concern—referencing ethical and legal constructs. Additionally, confirm the appropriate use of secondary data within the EHR.

Identify laws and regulations applicable to health care. Imagine that you are the Director of Health Information at a hospital and you have been asked to create a "one-page" pamphlet on the major laws and regulations related to health record retention and destruction. Draft an outline summarizing the top five best practices related to HIPAA, The Joint Commission (TJC), State law (select any state), and the Centers for Medicare & Medicaid Services (CMS).

Analyze legal concepts and principles in the practice of Health Information Management (HIM). A hacker has penetrated the network of the business associate providing cloud-based storage for the hospital, compromising all patient records from the last two months. As HIM Director, organize a response to this breach, differentiating the steps related to breach notification.

Evaluate how healthcare policymaking impacts the national and global healthcare delivery systems both directly and indirectly. Appraise one federal-level, one state-level, and one local-level healthcare policy on information privacy and security. Assess how each policy affects healthcare delivery across different levels, considering both immediate and long-term implications.

Paper For Above instruction

The integration of laws, regulations, and ethical standards in healthcare is vital for protecting patient information and ensuring high-quality care. This paper explores key components related to compliance in health information management, focusing on documentation accuracy, secondary data validation, legal frameworks, breach response, and policy impacts on healthcare systems.

1. Supporting Diagnosis and Reflecting Patient Progress in Medical Documentation

Accurate documentation forms the backbone of quality healthcare. In the case of the elderly patient transferred from a skilled nursing facility to an ICU and then to a LTCH, the health record must meticulously capture diagnostic data, clinical findings, progress notes, and discharge summaries. In skilled nursing facilities, documentation often includes nursing assessments, vital signs, care plans, and progress notes, which collectively support clinical status. ICU documentation emphasizes detailed ventilator readings, lab results, medication administration records, and detailed progress notes reflecting acute care interventions. Meanwhile, a LTCH emphasizes comprehensive discharge summaries, ongoing care plans, and rehabilitation progress. All these components demonstrate the continuum of care while validating the initial diagnosis and the patient’s clinical evolution.

The diagnosis must be supported by initial assessment data, laboratory results, imaging reports, and physician notes, which provide evidence of the clinical conditions and therapeutic interventions. Progress notes chart ongoing health changes, response to treatments, and stabilization efforts. Discharge documentation summarizes the patient's condition at transfer, functional status, and ongoing needs, providing a clear picture of clinical trajectory and outcomes. Such comprehensive documentation is critical for legal, billing, and healthcare quality assurance purposes.

2. Validation of Secondary Data and Ethical Concerns Encompassed by EHR Use

Validation of secondary data in the EHR involves ensuring the accuracy, completeness, and appropriateness of data entered by patients or third-party sources. Concerns arise when students or unauthorized personnel input data without proper oversight, risking data integrity violations. The ethical obligation to maintain confidentiality and data accuracy aligns with legal standards outlined in HIPAA, which mandates protected health information (PHI) security and authorized access. The portal glitch allowing patient-entered data to bypass physician oversight raises questions about data reliability and risk management. It could lead to potential misinformation, erroneous clinical decisions, or privacy breaches. Confirming appropriate use entails restricting patient entries to designated sections, implementing audit trails, and providing clear guidelines for data input. Ethical frameworks advocate for transparency, accountability, and safeguarding patient rights—principles that must be embedded in EHR management.

3. Key Laws and Regulations on Health Record Retention and Destruction

Creating a comprehensive pamphlet involves summarizing critical legal standards. Top five practices include:

- Understanding HIPAA’s Privacy and Security Rules ensure PHI is protected and disclosed appropriately.

- Adhering to The Joint Commission standards, which mandate retention periods and secure destruction methods to prevent unauthorized access.

- Complying with State laws— for example, California's Health and Safety Code—which specify minimum retention durations and destruction protocols.

- Following CMS regulations that govern Medicare and Medicaid record retention requirements, ensuring compliance for billing audits.

- Implementing institutional policies that define record retention timelines, secure storage, and proper destruction procedures, such as shredding or electronic data wiping, in accordance with applicable laws.

4. Legal and Ethical Response to Network Breach and Data Compromise

The recent breach via hacking necessitates a structured response plan. The steps include:

- Immediate containment: isolating affected systems and preventing further unauthorized access.

- Assessment and documentation: evaluating the breach scope, affected records, and entry points.

- Notification: informing affected patients, the business associate, and relevant authorities within 60 days, as mandated by HIPAA breach notification rules.

- Mitigation: offering credit monitoring or identity theft protection if PHI is compromised.

- Reviewing security protocols: strengthening firewall protections, updating antivirus software, conducting staff training, and implementing stronger access controls to prevent recurrence.

- Documentation of actions taken, demonstrating compliance and transparency in dealing with the breach.

5. Policy Impacts on Healthcare Delivery today and Tomorrow

Health policies at federal, state, and local levels significantly influence the integrity and security of healthcare systems. A federal policy such as the HIPAA Privacy Rule establishes nationwide standards for protecting PHI, fostering trust in electronic health exchanges, and ensuring consistent privacy practices. At the state level, California’s Confidentiality of Medical Information Act (CMIA) extends protections and mandates reporting of breaches, influencing regional data handling procedures. Locally, hospital-specific policies adapt state and federal guidelines to their operational context, affecting how patient data is accessed, stored, and transmitted. These policies collectively shape healthcare delivery by balancing information sharing with privacy rights, promoting secure EHR systems, and encouraging widespread adoption of telehealth and data sharing infrastructures. They directly impact patient safety, clinical workflow efficiencies, and global health initiatives like interoperable systems and cross-border health data exchange, ultimately improving outcomes and fostering innovation.

In conclusion, the integration of legal, ethical, and policy frameworks ensures health information is managed responsibly, supporting high-quality, secure, and compliant healthcare services. Continuous monitoring, training, and policy updates are essential for adapting to technological advancements and safeguarding patient rights on a national and global scale.

References

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• HHS Office for Civil Rights. (2020). Summary of the HIPAA Privacy Rule. U.S. Department of Health & Human Services.
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