In case of a late entry (addendum) in one, shadow chart or independent database, that is used to add information to a previous entry must have the title addendum, date, time, the reasons of creating the addendum referring back to the original entry (Legal Medical Records Standards). Information technology staff can help decrease incidents of security breaches by implementing screen protectors in all computers, by providing logging accreditation to all personnel, by using network security software and hardware, by monitoring the safety of the network and by educating, reporting and enforcing any HIPAA violation.
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In case of disclosure of unauthorized protected medical information such as providing a copy of medical records to a friend of a patient without written authorization from the patient may result in fines and imprisonment to the institution and individuals involved in such HIPAA violation. HIPAA defines as criminal the use or disclosure (by individuals or institutions) of confidential medical information of a patient for any other purposes than treatment, payment, or health care operations. Such violations carry fines and/or imprisonment (Privacy, Security, and Confidentiality).
According to the Montana Code 41-1-402 the healthcare provider can obtain a legal consent for prevention, diagnosis or treatment from a minor (without adult supervision) if the minor is graduated from high school, have a child, lives alone and supports him (her) self, is pregnant, infected with a infectious disease, is under the influence of alcohol or drugs. In the case of pregnancy, sexually transmitted diseases or substance abuse the healthcare provider is obligated to provide counseling to the minor or refer the minor for counseling.
Finally, in case of emergency the health provider can provide emergency care without consent and must inform the parents or legal guardians as soon as possible. One situation from Montana Code 50-16-603x which may result in a legal claim against the organization can be if the health care provider fails to report any communicable disease (such as tuberculosis) to the proper authorities; resulting in a potential health risk to the population and penalties to the organization and health care providerwhich committed such HIPAA violation.
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In the case of a minor unable to consent or make decisions (due to a mental condition or conscious state) and the absence of parents or legal guardians, two medical doctor must make all medical decisions on his behalf including cardio pulmonary resuscitation andtermination of life support. Montana codes are in agreement with HIPAA laws in the following clauses regarding release of personal health information (PHI). According to HIPAA’s Privacy Rule the individual has the right to inspect and request a copy of his PHI upon a writing authorization.
Under HIPAA law the healthcare provider can share PHI information with public health authorities for public health purposes such as prevention, statistics, research and education. Under HIPAA law the health care provider may share PHI to business associates for treatment, payment and healthcare operations (HIPAA Privacy Rule and Public Health). 2. (c) A health care provider may deny access to health care information by a patient mentally impaired by disease, medications, drugs or alcohol used at the moment of the request References
Legal Medical Records Standards, Annotated 2008. Retrieved from www. ucop. edu/ucophome/coordrev/… /legal-medical-record-policy. p… Montana Code, Annotated 2009. Retrieved from http://data. opi. mt. gov/bills/MCA_toc/index. htm Privacy, Security, and Confidentiality. Retrieved from http://www. ahima. org/resources/psc. aspx HIPAA Privacy Rule and Public Health “Guidance from CDC and the U. S. Department of Health and Human Services “Annotated 2003. Retrieved from http://www. cdc. gov/mmwr/preview/mmwrhtml/m2e411a1. htm