Here I address the needs absent from two health record policies, and specific liabilities of the Montana Code. H.I.M. Policy is specific to confidentiality, privacy, accuracy, and accountability. These aspects are highlighted in this exercise, referencing the needed addendum of a shadow chart policy along with staffing educational requirements in regard to information security. Likewise, the address will recognize the laws and how they shape policy in healthcare.
Legislative and Legal Systems
As a rule, shadow charts should contain copies of information from a patient’s primary chart. In some cases, the shadow chart may contain original information meant for the patient’s ...view middle of the document...
In the situations presented in the reference of Montana Code 41-1-402 (2a-2d), the evolved right of a minor to consent for treatment, the clinical and H.I.M staff must abide by HIPAA guidelines in securing information (DOHHS, 2006). Failure to protect the emancipated minor’s health record would result in an HIPAA violation which as defined by The U.S. Dept. of Justice to be criminally liable as following (Nutter and Fish, 2009)
* Use of or caused use of a unique identifier
* Obtaining individually identifiable health information relating to an individual
* Disclosure of individual identifiable health information to another person
As explained by the U.S. Department of Justice, an individual who “knowingly” breaches these rights can be held criminally liable under HIPAA (AMA 2013). As per Montana Code 41-1-402, any patient, who is an emancipated minor, is entitled to treatment, confidentiality and privacy of information from all unauthorized persons. Likewise, a minor unaccompanied by parent or guardians declaring self-support, is entitled to treatment under the Montana Code. Refusal of treatment of a minor able to consent is criminally liable. Discussion with a 3rd party by clinical staff concerning the (minor) patient’s treatment or care, without consent from the patient, is deemed criminally liable. This portion of the Montana Code ensures the treatment of minors by the medical staff in the absence of an adult.
Confidentiality of Information
Montana Code 50-16-603 addresses issues of confidentiality. An example used from 50-16-603 (1) states exceptions to withholding information in “For statistical purposes, if no identification of individuals can be made from the information released”. The importance of this policy is stems from protection of patient confidentiality. Some insurances or government affiliates may use patient information for statistical measures while retaining confidentiality. An example would be history of tobacco use in lung cancer patients. Privacy is protected under the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, 2002).
In teaching environments, it is not uncommon for the clinician to use real-world examples provided by actual patients. An example would be an Oncologist using a chest x-ray of his patient to depict how a cancer is seen in a radiograph. While done commonly, this practice could lead to unintentional HIPAA violations unless specific measures are followed for de-identification. After de-identification, the rules of HIPAA no longer apply (DOHHS, 2006).
Adequate statement of Montana Code 50-16-603 concerning confidentiality of health records must contain specific requirements for release. The following is reprehensive of that policy requirement.
Confidential records are only released when permitted by law or proper written authorization of the patient. Authorization is to...