Department of Health Informatics and Information Management
HIM 3132 – Medicolegal Issues
Unit 4, Ch. 9 Legal Health Record Case Study
Releasing Health Information for Subpoenas
The director of health information management, as the custodian of medical records, is having a great deal of difficulty responding to subpoenas for patient records. The facility is in the midst of converting from a paper-based to an electronic patient record. Some information is on paper (such as consents), some information is scanned immediately following discharge (such as nurses’ notes), some information is automatically fed into the EHR system (such as transcription reports) and some information resides within electronic systems (such as lab results and physician orders). The process of finding and identifying the various parts of the patient’s record from the various sources is time-consuming and there is concern about ensuring the same response (that is, that the legal health record is produced) each time a record is requested. An attorney requested a record, followed by an additional request. What he received from the organization the first time was substantially different from what he received the second time. When the attorney deposed the custodian, many questions were raised about how record requests were handled, daily operational processes including how the patient’s legal health record was compiled in response to this subpoena, and if this was the true and complete record for the patient.
Assignment Requirements (*see grading rubric for additional requirements)
Part 1: Develop a 2 page essay, double spaced, Times New Roman, 12 point font addressing the question below. You should incorporate information from the text and course readings to support your answers. The text and other resources you use to address the questions should be cited on a reference page and within the paper as “in text” APA citations. Please see the CSS Library APA resources at https://libguides.css.edu/APA7thEd.
Address the following question in relation to the case above, incorporating information from the readings to support your answers.
● What three steps should the director take to assure that responses to subpoenas (that is, the legal health record) consist of the same information?
Part 2: Create a Policy and Procedure for Use and Disclose of Health Information for Subpoenas
You will create a policy and procedure on how your organization will respond to subpoenas request to ensure integrity and availability of releasing the data. You are expected to research requirements and incorporate them into your policy and procedure.
Sample Procedures (please do not just copy – only use as a reference):
*note: these are exceptionally long policies. Your policy/procedure is NOT expected to be of this length. These are merely examples.
Health Point Subpoena of Medical Records http://www.bvcaa.org/HSPP/Administrative%20P&P/Front%20Office/Subpoena%20of%20MR%207.2014.pdf
Florida Atlantic University Accounting of Disclosure of Protected Health Information
Perform your own Internet search to find more examples