Running Head: HIM bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb b
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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).
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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.
