Hi 135 Unit 9: Complying With Laws And Regulations

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 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 acute 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 or 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. To make matters worse, a glitch is present in the new patient and physician portals. Patients can enter data into their own records and physicians cannot enter data.

In an executive summary, justify your rationale for concern—referencing ethical and legal constructs. Additionally, confirm 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 (5) 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 HIM. A hacker has penetrated the network of the business associate providing cloud-based storage for the hospital. All patient records within the last two months were compromised. As HIM Director, you have been tasked with organizing a response to this breach. Differentiate the steps related to breach notification.

Evaluate how healthcare policymaking both directly and indirectly impacts the national and global healthcare delivery systems. Appraise one (1) federal-level, one (1) state-level, and one (1) local-level healthcare policy on information privacy and security. Evaluate how each policy affects national and global health delivery systems—both directly and indirectly.

Paper For Above instruction

In today’s healthcare environment, compliance with legal and regulatory frameworks is paramount to ensure the protection of patient information, uphold ethical standards, and optimize healthcare delivery. This paper addresses key aspects of healthcare law and ethics, focusing on documentation practices, data validation, legal regulations, breach response, and policy impacts, through a comprehensive, scenario-based exploration aligned with the specified assignment components.

Part 1: Supporting Diagnosis and Reflecting Patient Progress

Supporting documentation within health records is critical in validating a patient’s diagnosis, clinical findings, progress, and discharge status. For the case of the 80-year-old male patient, whose daughter has POA and access rights, proper documentation across different care settings ensures transparency and continuity of care. In the ICU, documentation includes progress notes detailing vital signs, hemodynamic stability, laboratory results, and interventions, which substantiate critical diagnoses such as sepsis or respiratory failure. The ICU flow sheets and physician orders provide real-time evidence of his condition and treatment trajectory.

Transitioning to the skilled nursing facility (SNF), documentation composes nursing assessments, medication administration records, therapy notes, and the comprehensive care plan. These elements reflect ongoing clinical findings, recovery progress, and response to treatment. Upon transfer to the LTCH, documentation emphasizes rehabilitation progress, discharge planning, and complex chronic condition management, consolidated within the transfer summary, which includes diagnoses, medications, and care needs. These components collectively support the clinical narrative necessary for accurate diagnosis and tracking of the patient's condition through different phases of care.

HIPAA regulations mandate that such documentation must accurately reflect the clinical scenario while maintaining confidentiality. The accuracy and completeness of these records are essential for legal compliance, reimbursement, and quality assurance. As J. Keller & Associates (2011) emphasize, precise documentation supports legal defensibility and clinical integrity, especially during cross-setting transfers.

Part 2: Validation of Data from Secondary Sources

In a large teaching hospital, ensuring the integrity of secondary data sources within the EHR is vital. Student rotations have increased the risk of improper use of EHR, especially amid technical glitches allowing patients to input data directly, bypassing physician verification. This situation raises ethical concerns rooted in principles of beneficence and non-maleficence, as inaccurate data can compromise patient safety and quality care (Amatayakul & American Medical Association, 2013).

Legally, the misuse or inadvertent entry of incorrect data violates HIPAA and patient privacy statutes. It also undermines data integrity mandated by CMS and TJC standards. Validating data from secondary sources involves cross-checking patient-entered information against clinical records, verifying authenticity, and ensuring all data entries are correctly attributed and reviewed by authorized personnel (Trinckes, 2012). Establishing protocols for data validation and staff training is essential to uphold ethical standards and legal compliance.

Part 3: Laws and Regulations on Record Retention and Destruction

Developing a one-page pamphlet on healthcare laws requires summarizing best practices related to HIPAA, TJC, state law, and CMS. Top five practices include:

• Understanding federal record retention requirements under HIPAA (usually 6 years from the date of creation or last use).
• Complying with TJC’s standards for documentation and record retention to support accreditation and quality standards.
• Adhering to state-specific laws—such as California’s laws mandating retention periods and destruction protocols for health records.
• Implementing secure, monitored procedures for record destruction, ensuring all data is irretrievable to prevent unauthorized access.
• Maintaining accurate records of destruction activities for audit purposes and legal compliance.

This outline ensures that health records are managed responsibly, balancing documentation requirements with privacy and security obligations.

Part 4: Legal Concepts and Breach Response

In the event of a network breach involving cloud storage, compliance with breach notification laws is mandated. The HIPAA Breach Notification Rule specifies that covered entities and business associates must notify affected individuals without unreasonable delay and within 60 days of discovering a breach (HHS, 2023). The notification process involves identifying the breach, assessing scope, and informing patients, the Department of Health and Human Services (HHS), and, if applicable, media outlets. The response protocol includes forensic investigation, documentation of incidents, containment measures, and policy updates to prevent future breaches. The distinction between breach detection, containment, notification, and remediation is critical to legal compliance and maintaining public trust.

Part 5: Impact of Healthcare Policies on Systems

Healthcare policymaking at various levels has profound effects on national and global health systems. Federally, the Health Insurance Portability and Accountability Act (HIPAA) sets standards for privacy, security, and breach notifications, directly impacting how data is protected across the United States (HHS, 2023). State policies, such as California’s Confidentiality of Medical Information Act (CMIA), further augment privacy protections, influencing regional practices and legal standards. Locally, hospital-level policies on data encryption, staff training, and incident response shape day-to-day operations and patient trust.

These policies combine to form a layered framework that governs data handling, promotes interoperability, and encourages global health information exchange. Indirectly, these policies affect healthcare accessibility, quality, and efficiency by fostering innovation in health IT, telemedicine, and international health collaborations. Effective policy implementation reduces disparities, enhances data integrity, and supports rapid response to health emergencies on a global scale (Taylor et al., 2015).

As healthcare becomes increasingly interconnected, understanding the layers and impacts of these policies allows for strategic planning and compliance management, which are essential for safeguarding health information and advancing global health objectives.

References

• Amatayakul, M., & American Medical Association. (2013). Handbook for HIPAA/HITECH Security. Chicago, IL: American Medical Association.
• Healthcare Executive. (2015). Communication Strategies for Healthcare Workers, 30(6), 42.
• HHS. (2023). Health Insurance Portability and Accountability Act (HIPAA). U.S. Department of Health & Human Services. https://www.hhs.gov/hipaa/index.html
• J. Keller & Associates. (2011). HIPAA Compliance Manual for Employers.
• Trinckes, J. J. (2012). The Definitive Guide to Complying with the HIPAA/HITECH Privacy and Security Rules. Boca Raton, FL: Auerbach Publications.
• Journal of Health and Human Services Administration. (2015). ENHANCING COMMUNICATION BETWEEN PATIENTS AND HEALTHCARE PROVIDERS: SBAR3.
• Taylor, J. F., Williams, R. L., & Blythe, M. J. (2015). Healthcare reform, EHRs, and adolescent confidentiality. Contemporary OB/GYN, 8, 34.
• Centers for Medicare & Medicaid Services. (2023). Data Retention and Record Destruction Policies. CMS Guidelines.
• State of California Department of Public Health. (2023). Medical Records Retention and Destruction Regulations.
• American Medical Association. (2022). Data Security and Patient Privacy in the Digital Age. AMA Reports.