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1-2 Journal: eDiscovery and Business Record Rules
HIM 422
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• A Health Information Management (HIM) professional must be fluent in processes
relating to subpoenas, discovery, depositions and eDiscovery. These processes are of high
relevance in the context of litigation. Szalados has argued that lawsuits in the medical
landscape can be unnerving for professionals that function in the healthcare domain
(Szalados, 2021). A considerable degree of demand may be placed on an HIM
professional in legal processes, specifically when it comes to the use of health
information in any lawsuit. Thus, it becomes a necessity for these professionals to have
a clear understanding of what is expected of them and how they can exercise their roles
and responsibilities in the legal context.
Russa has argued that the possibility of litigation is high in the healthcare context
(La Russa et al., 2021). Thus, HIM professionals must have proper comprehension
relating to these aspects since they have the ownership of their legality. The
understanding of these important processes can aid HIM professionals in effectively and
responsibly releasing the relevant protected health information of patients within
healthcare facilities (Bowman, 2013). By having comprehensive insight into the processes,
HIM professionals will be able to act as the ultimate ‘custodian of health records’, and
they may be called for testifying purposes relating to the admissibility of the health
records. Only if an HIM professional has proper insight into the diverse processes will
he or she be able to verify the timeliness and the adoption of normal business practices
while developing and maintaining the health records. It can help to adopt effective
strategies to approach healthcare-related litigations (Machado et al., 2021).
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• In order to successfully respond to cases relating to negligence, malpractice,
corporate negligence, or breach of confidentiality, it is imperative to identify the changes
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that might have taken place in each of the processes. As per the business record rule,
there is scope to admit records as a piece of evidence as long as there exists a proper
foundation that shows that the document is reliable. It is necessary for healthcare
organizations to ascertain how their information systems can provide for the preservation
of details and information that may be relevant in the litigation process. The policies,
protocols, and practices that exist in place must aid the staff in understanding how they
can help in maintaining the records so that they will be able to meet necessary federal
as well as state legal requirements (Bowman, 2013). The key steps that entities need to
take into consideration in order to make sure that litigation is successful include
recognizing which specific department would be responsible for handling the request and
representing the organization in the court of law. Similarly, another key step that must
be taken involves the proper establishment of policies and protocols which can assist in
determining which specific record would be disclosed and preserved during the litigation
process. Additionally, it is necessary to ensure that the staff members possess a
substantial level of knowledge and understanding relating to the policies and practices
that have been introduced in the organizational context prior to the submission of the
key documents as pieces of evidence in the court of law.
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References
Bowman, S. (2013). Impact of electronic health record systems on information integrity:
quality and safety implications. Perspectives in health information management,
10(Fall).
La Russa, R., Viola, R. V., D’Errico, S., Aromatario, M., Maiese, A., Anibaldi, P., ... &
Fineschi, V. (2021). Analysis of inadequacies in hospital care through medical
liability litigation. International Journal of Environmental Research and Public
Health, 18(7), 3425.
Machado, F. L. D. S., dos Santos, D. M. D. S. S., & Lopes, L. C. (2021). Strategies to
Approach Medicines Litigation: An Action Research Study in Brazil. Frontiers in
pharmacology, 12, 418.
Szalados, J. E. (2021). The Timeline of a Medical Malpractice Lawsuit. In The Medical-
Legal Aspects of Acute Care Medicine (pp. 117-135). Springer, Cham.
