Explain the four elements of negligence that must be present in order for a plaintiff to recover damages?
Discuss the purposes for which the health record is maintained within a healthcare organization.
Explain the concept of e-discovery and discuss the role of health information management professionals in the e-discovery process.
What are the differences between a living will and a durable power of attorney for healthcare?
The corporate director of risk management is asked to review a patient’s health record in preparation for legal proceedings for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longstanding history of being non-compliant with the organization’s record completion policies, and previous concerns regarding this physician’s record maintenance practices had been reported to the organization’s credentialing committee.
Apply appropriate legal concepts to demonstrate why this health information may not be admissible in court.
What judgment, if any, regarding negligence could be made against the organization?
Purposes of the Health Record
Health records are maintained within a healthcare organization for a wide array of interconnected clinical, legal, and operational purposes:
Clinical: To provide a complete, chronological account of the patient's care, allowing for continuity of care across providers and settings, supporting clinical decision-making, and documenting communication among caregivers.
Legal: To serve as the official business record of the organization. The record is critical for defending the organization and providers in malpractice suits, regulatory compliance, and fulfilling discovery requests during litigation.
Financial: To substantiate the services provided for reimbursement from third-party payers (Medicare, Medicaid, insurance companies). Documentation must accurately reflect the codes used for billing.
Administrative/Operational: To provide data for quality assessment and improvement (QI) initiatives, accreditation processes (e.g., The Joint Commission), professional credentialing, and organizational planning.
Research and Education: To serve as a data source for medical research and to provide case examples for training future healthcare professionals.
Sample Answer
Elements of Negligence
A plaintiff must prove four specific elements of negligence were present in order to recover damages in a malpractice case:
Duty of Care: The defendant (healthcare provider) owed a professional duty to the plaintiff (patient). This duty is established upon the initiation of a provider-patient relationship and requires the provider to act as any reasonably prudent professional would under the same or similar circumstances.
Breach of Duty: The defendant failed to meet the standard of care owed to the plaintiff. This failure constitutes a deviation from the accepted professional practice.
Causation: The defendant's breach of duty was the direct and proximate cause of the plaintiff's injury. The injury would not have occurred but for the defendant's negligent act.
Damages (Injury): The plaintiff suffered legally recognizable harm, injury, or loss (e.g., physical injury, emotional distress, financial loss) as a result of the breach.