Legal and Ethical Considerations - Task 1
Running head: LEGAL AND ETHICAL CONSIDERATIONS – TASK 1
Legal and Ethical Considerations – Task 1
Name
Western Governors University
Legal and Ethical Considerations – Task 1
A shadow chart is a partial copy of a patient’s medical history, kept by health care providers or departments for the sake of convenience. A shadow chart is not part of the official medical record. It is a working document where information can be added and removed as necessary to aid in the decision-making process. It may include reminder systems, scheduling information, research activities, and information not considered appropriate for the permanent record. It is frequently used to support inter-professional or inter-departmental communication.
Shadow charts are usually products of paper records, and hybrid record systems, which are combinations of both paper and digital files. There are inherent problems associated with shadow charts. Because they contain protected patient information, they are often subject to security breaches, as they are frequently left in unsecure locations. They may contain original documents and data that should be part of the permanent record, but never become part of the permanent record. Shadow charts do not contain the most current information. Computer databases that have been independently created, usually for research purposes, have the same inherent problems as shadow records.
Release of Information: Shadow Chart Policy
A shadow chart is a duplicate health record kept for the convenience of the medical provider. In the event that authorized individual requests health information pertaining to a specific episode of care, health information management staff will review any shadow charts kept by medical providers for that patient to determine if any such shadow charts contain information related to the episode of care. If the shadow chart contains information related to the episode of care and is not
Legal and Ethical Considerations – Task 1
Name
Western Governors University
Legal and Ethical Considerations – Task 1
A shadow chart is a partial copy of a patient’s medical history, kept by health care providers or departments for the sake of convenience. A shadow chart is not part of the official medical record. It is a working document where information can be added and removed as necessary to aid in the decision-making process. It may include reminder systems, scheduling information, research activities, and information not considered appropriate for the permanent record. It is frequently used to support inter-professional or inter-departmental communication.
Shadow charts are usually products of paper records, and hybrid record systems, which are combinations of both paper and digital files. There are inherent problems associated with shadow charts. Because they contain protected patient information, they are often subject to security breaches, as they are frequently left in unsecure locations. They may contain original documents and data that should be part of the permanent record, but never become part of the permanent record. Shadow charts do not contain the most current information. Computer databases that have been independently created, usually for research purposes, have the same inherent problems as shadow records.
Release of Information: Shadow Chart Policy
A shadow chart is a duplicate health record kept for the convenience of the medical provider. In the event that authorized individual requests health information pertaining to a specific episode of care, health information management staff will review any shadow charts kept by medical providers for that patient to determine if any such shadow charts contain information related to the episode of care. If the shadow chart contains information related to the episode of care and is not
References: Amatayakul, M. (2003). HIPAA reins in shadow charts, independent databases. Journal of AHIMA, 74(9), 16A-C Centers for Disease Control and Prevention. (2012). Global Health – International health regulations (2013). National notifiable infectious conditions. Retrieved from http://wwwn.cdc.gov/nndss/script/conditionlist.aspx?type=0&yr=2013 Centers for Disease Control and Prevention, Global Health – International Health Regulations. (2012). Spotlight. Retrieved from http://www.cdc.gov/globalhealth/ihregulations.htm Certified copy law & legal definition MT Code § 41-1-402 (2013). LaTour, K. M., Maki, S. E., & Oachs, P. K. (2013). Health information management: Concepts, principles, and practice [P2B5-05]. Nutter McClennen & Fish LLP, & Sethi, M. L. (2009, May 28). United States: Criminal liability for the wrongful use of health information: HIPAA and more Retrieved November 18, 2013, from http://tulane.edu/counsel/upco/upload/006-Designated-Rec-Sets-rev7-2013.pdf U.S