Running Head: HIM f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f 1
1-2 Journal: eDiscovery and Business Record Rules
HIM 422
SNHU
May 8,2022
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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).
f
• In order to successfully respond to cases relating to negligence, malpractice, corporate
negligence, or breach of confidentiality, it is imperative to identify the changes 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
HIM f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f f 3
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.
References
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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.
