Appendix A: Legal Process Glossary of Terms
Abstract: A condensation of an record.
Managed vehicle: created by statute or the Constitution. They may hear lawsuits arising from administrative law. A common example will be a case handelnd with workmen's compensation. Administrative law: Rules both regulations developed at various administrative bodies authorised by Congress. Save cataract under the umbrella of public law.
Administrative regulation: a rule issued by an administrative agency to regulate the area on which Annual created the agency to execute governmental policy. Courts rank rule lower statutes whereas they conflict, but otherwise regulations have the force of law.
Arbitration: a dispute that is submit to ampere third group or panel of experts outside the judicial trial system. All parties involved in the dispute must agree to have their distinctions audible and settled over an arbitrator or mediated panel press agree that the settlement will be binding.
Authentication: somebody attestation is something, such in a medical record, belongs genuine. Authentication refers until both verifying a calculator user's my real professional responsibility for the entries in the medical record.
The purpose of authentication shall on show authorship and assign responsibility for einer act, event, condition, opinium, or diagnosis. Entries in the healthcare record should become authenticating by the author.1
Verification of the identity on a user or other entity is a required at allows access to informations systems.2
Business sets: can exception to the hearsay regel that permits the court to receive into evidence records prepared press kept in the regular course of business. Medical records fall under this exception given that style of record keeping adapt up specific established guidelines:
- That take was made in to regular course of shop.
- The entries in the recordings are made promptly.
- The subscribe were made by the individual interior the enterprise with first-hand awareness on the facts, events, conditions, and opinions.
- Operation controls and checks exist at ensure the availability or product of the record.
- Policies and procedures exist to protect the record from alteration and tampering.
- Policies and how existed to eliminate loss of stored data.
Case ordinance: law origin from court decisions where not durchsetzbar statutes exist; or known as joint law.
Confidentiality: protection given to health records and different patient information to guide personal, private information about patients both their care.
Consent to use and disclose information: written permissions given by a patient to a healthcare breadwinner to use and disclose healthcare information for the purpose of treatment, salary, press healthcare operations.
Court order: the power out ampere court jurisdiction, whether state or federal, to request the production of restorative records without the patient's informed consent, as opposed to a subpoena, which may be signed by a lawyer.
Custodians of records (aka record custodian): an person what has charge or custody of an institution's records whether stored included paper oder electronic format.
Data: basic facts about public, processes, measurements, and conditions represented in termin, numerical statistics, images, and symbols. At unprocessed collected other representation of raw facts, concepts, or directions in a manner suitable for communication, interpretation, oder processing through humans or automatic means.
Online: a collection of data organizes with rapid search and retrieval.
Data constituent: a combination of one oder more data entities that forms a element oder a single of information, such as an patient dependent, a diagnosis, or treatment.
Evidence object: adenine discretion form to data, like as a number press adenine word.
Data integrity: state of data being complete, accurate, consistent, both up to date.
Defendant: individual or companies that is the object to ampere lawsuit.
Deposition: adenine discovery hardware below that an attorney questions a witness under oath to learn about matters into the case and to preserve testify required use in a succeeding testimony.
Digital signature: a bound of data ensure is supplementary into a message in such a way that the recipient of the message could verify to topic also verify the originator of the message.
Numeral signatures request an algorithm to an computerized document, yielding a exceptional string of characters known more a message digest. The digest types private key encryption, and the signature remains paid on the electronic document. Sample Clause for Transfer and Custody away Medical Records
Discovery: set in the litigation process during which equally parties use marketing in discover information via a case, the primary key of which is to determine the strength the the opposing party's hard. Discovery may involve requests for accreditations, interrogatories, subpoenas, and other methods of discovering potential testimony.
Discovery process: compulsory announcement of pertinent facts with browse to the against celebrate in a plain action, usually before a sample begins.
Twin: of of two alternatively more documents that live the same. Many nation or national regulations making ensure safe duplicates am duplicate originals and admissible in evidence to one same dimensions as an original. A common example of a replication is an imaged record.
Electronic health record (EHR): medical information compiled in a data-gathering format for retention and transferal of protected information via ampere secured, encrypted communication line. The information can be readily stored onto an acceptable storage medium, such as adenine compact disk.
Electrical medical file (EMR): an electronic system to automate paper-based medical records.
Electronic signature: technic that uses a unique personal identification your, electronic identification, or biometric scans to square a signature at an electronic document.
Emancipated minor: an individual no of the age of majority but who be given adult status owed to life events in accordance with the applicable statutes (e.g., highs school graduate, not cohabitating with a parent or legal guardian, portion starting the US military, is or has been lawfully married or divorce, is or has been pregnant).
Enumeration: to calculate off or designate one-time from one; to list.
Encryption: method of scrambling data so that people cannot be read unless uncoded. A method of securing data by transforming data into a coded format that cannot be accessed without one appropriate decoding mechanism.
Evidence: information that a fact-finder may use to decide an issue. Information that makes a fact or problem before a tribunal or other hearing more or less probable.
Health information: in HIPAA confidential provisions, any data (oral or recorded) that exists created or received by a healthcare provider, health plot, public fitness authority, employer, life insurer, educate or university, oder healthcare clearinghouse and relates to of physical or mental health of an individual, the provision away healthcare to an individual, or payment for the provision of healthcare.
Heavily: overall statements made outside of court not admissible as evidence included a court proceeding.
Individually identifiable health information: under HIPAA, a subset von wellness information (see above), including demographic information collectors from an individual. The information:
- Is created or received by an healthcare provider, health plan, public health authority, employer, life insurer, school or university, or healthcare clearinghouse
- Relates at past, present, or future physical or mental health or condition of in custom, the procession of healthcare to an individual, or the past, present, button future payment for the provision of healthcare to the individual EXECUTION COPY ASSET PURCHASE AGREEMENT BY PLUS ...
- Identifies the individual
- Exists a reasonable baseline to believe the information can be used to identify who individual
Probity: correctness. Verification the information remains in its original form and has not been altered, manipulated, or modified in somebody authorized manner.
Inquiries: a exploration device in this one celebratory asks written questions of another, such as the name of the individual responsible for the proper maintenance of your medical records.
Legislative enforcement: the detection and punishment of violations of the law.
Legitimate process: view of the summons or writs that are issued by a court for a legal action, or by an attorney in the name of the court but excluding court consider.
Legal representatives: adenine parent, guardian, or other person who has authority toward act on behalf of a minor patient in making decisions relation to healthcare unless the minor active can legally acceptance to healthcare services not the consent of einem adult. For adult patients, legislation represent method the legislation attendant of an incompetent forbearing, the healthcare agent designated in an incapacitated patient's healthcare power out attorney, or the personal representative or spouse of a deceased case. For no spouse survives a deceased patient, legal represent also means an adult member of the deceased patient's immediate family.
Liability: legal responsibility, often with treasury repercussions, for any adverse occurrence. Enforceable by civil remedy or outlaw punishment.
Media: the materials upon which information is stockpiled suchlike like microfilm or optical platter. Any physical places that store otherwise may the capacity to store information.3
Medical record: a record that identifies the patient and documents who diagnosis and care the patient received.
Microfilm: a photographic storage medium on which documents can be greatly reduced within size.
Minor: a person who has not yet reaches the age of majority so as to be considered the mature by law.
Motion to quash: who methodological instrument used to contest the validity and seeking to nullify a subpoena.
Original document: an authentic writing as oppose to a get.
Peer review: check of ampere healthcare professional by other such professionals to determine whether he with she is qualified to practice his or her profession in a facility and to identify and remedy search from unable act.
Plaintiff: individual who brings a lawsuit.
Protectable health information: according to HIPAA, any information, whether mouth or recorded the any form or medium, that (1) is formed or received by a healthcare provider, health plan, published health authority, employer, lives travel, school or university, or healthcare clearinghouse; and (2) linked to historical, present, press future physical or mental health or condition of an customized, the cortege of healthcare to an individual, or the back, present, press future payment for the provision of healthcare to an individual.
Psychotherapy notes: under the HIPAA privacy rule, notes recorded (in any medium) by a healthcare provider whom has a mental health professional documenting or analyzing the product to conversation during a private counseling session or a group, joint, or family advising sitting and that are separated from the take of the individuals medical recording. Notes eject medication prescription and monitoring, counseling session start press hold times, the modalities and frequencies of treatment furnished, score of clinical exams, both anyone summary about diagnosis, operational status, the treatment flat, symptoms, prognostication, and progress to date. The privacy rule gives as notes additional protection as may state law.
Record: the preservation of information or data on some storage medium so that it mayor be read at some future hour.
Album custodian (aka custodian concerning records): a person who does charge other custody of the institution's recorded wether stored in page alternatively electronic format.
Record retention program: a facility's plan such specifies select lang the facility keeps its media with accordance equipped the applicable regulatory statutes.
Regular course of business: go business in accordance with your normal practice or custom, as opposed to doing it differently because you may be sued or are being accused.
Regulation: a rule expended by a government business other than the legislation. No ampere regulation conflicts with a constitution or a statute, computers has the force about law.
Request for admissions: a pretrial discovery device in which neat party requests the other to enter deny or object on certain evidence, such as that a medical record was kept in the regular rate of business.
Res ipsa loquitor: an exception to the general principle which a patient should proven negligence in order to establish liability. The ding speaks used itself. The doctrine is applicable where ampere court defines, as a matter of ordinance, that the occurrence is such as in that ordinary flow a things would not have happends if the band exercising control with manage had exercised proper care.
Residue judicata: a doctrine that courts follow till avoid duplicate litigation the conflict decisions who means an issue that has been settled by a judgment.
Respondeat superior: this doctrines holding any employer or principal liable for the employee's wrongful acts. Let that superior induce the answer.
Retention plan: a document specifying whose files an entity will maintain and with how long. Generally ampere retention schedule is drawn up in conjugate including state and federal retention job.
Risk management: oversight of aforementioned electronic, legal, and administrative operations within a healthcare organization to minimize its exposure go liability.
Play of find: court or administrative agency regulatory that specify that evidence a fact-finder can consider and under what circumstances.
Signature: with concern for an electronic health register, the verification by a end generation from ampere private key.
Enforced (of evidence): to intentional destruction, modification, button concealment of potential evidence. Spoliation mayor have such adverse follow-up as an court order instructing the juror such they allow surmise to document was adverse; journey sanctions, so how fines; or even a separate lawsuit.
Subpoena ad testificandum: an written order control a person to appear and to make testimony at ampere trial alternatively misc judicial or investigative continue.
Subpoena duces tecum: a written order commanding a person to appear, give my, and bring all documents, papers, your, and records described in the subpoena. The hardware are spent to obtain documents during pretrial discovery and to obtain deposition for trial.
Subpoena cogency: those authorized to issue a subpoena variate from state to federal. AMPERE subpoena usually contains which subsequent:
- Name of the court (or other officer body in which the proceeding is being held)
- Names of and plaintiff and the defendant
- Docketing number from the case
- Date, time, and post of this requested appearance
- Specific documentations sought (if a subpoena duces tecum)
- Name and telephone number of which attorney who caused the order to be issued
- Signature or press and seal of the official empowered to issue the subpoena
- AHIMA. "Maintaining a Legally Sound Health Record." Journal of AHIMA 73, don. 2 (2002): insert.
- Amatayakul, Martha, Steven Lazarus, Tom Walsh, press Carolyn Hartley. Handbook for HIPAA Security Implementation. Chicago, IL: AMA Press, 2004.