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You are here > Home > Reading Lists > Law, Malpractice & Compliance > Medical Records & the Law

Medical Records and the Law, 4th Edition
William H. Roach, JD

4th Edition
Hardcover: 500 pages
ISBN 0763734454
9780763734459
Jones & Bartlett
April 2006
(click button below for the very best currently available price for this important resource)

Published in conjunction with the American Health Information Management Association (AHIMA), the 4th Edition of Medical Records and the Law is once again the ideal text for programs in HIM as well as a valuable reference resource for health professionals and those in the legal profession.

Providing a useful resource to those in the legal profession, it addresses the substantial changes brought about by HIPAA and the growth of electronic health record systems and electronic data networks, retaining and updating the discussion of state laws affecting the use and disclosure of health information. New legal issues arise when information is integrated and widely available in different electronic formats to a growing number of players in the health care delivery system. 

The legal issues surrounding technological advances in computer-based patient records, electronic links between patients and providers, telemedicine, community-wide information systems, and access to patient record information are addressed. HIPAA has completely changed the landscape of health information management. Changes to the 4th edition will include substanative changes to every chapter to reflect pervasive impact of HIPAA. A new chapter has been added concerning health information in medical research. New developments such as telemedicine are covered as well. It addresses the issues associated with managed care and advances in computer technology that have occurred since the last edition.

The implications of new Federal regulation of the confidentiality of health care information, an overview and discussion of state and Federal regulation of managed care, provisions governing electronic payment claims contained in the Health Insurance Portability and Accountability Act and their impact on the transmission of other forms of health care information will all be features of the third edition of Medical Records and the Law. Contents of this book include: 

  • Introduction to the American Legal System 
  • Medical Records and Managed Care
  • Medical Records Requirements
  • Medical Record Entries
  • Documenting Consent to Treatment
  • Access to Medical Record Information
  • Reporting and Disclosure Requirements
  • Documentation and Disclosure: Special Areas of Concern
  • HIV/AIDS: Mandatory Reporting and Confidentiality
  • Discovery and Admissibility of Medical Records
  • Legal Theories in Improper Disclosure Cases
  • Risk Management and Quality Review
  • Computerized Medical Records
  • Glossary: Acronyms and Definitions
  • Index 

The American Health Information Management Association (AHIMA) is the community of professionals engaged in health information management, providing support to members and strengthening the industry and profession. A world in which the public values the contribution of health information management professionals and the American Health Information Management Association, in the advancement of health through quality information: 1) Provides career, professional development and practice resources; Sets standards for education and certification; and, Advocates public policy that advances HIM practice. AHIMA fosters the professional development of coding professionals through advocacy, education, certification, and lifelong learning opportunities.

"This book is a presentation of the law regarding medical records, including the latest trends in health information management... The purpose is to analyze the legal issues affecting health information management. This is a very important issue today, with technological advances creating all sorts of scenarios in recordkeeping that would not have been possible in the past. This book is intended for attorneys and healthcare providers. It should be useful to both -- the author avoids arcane legal terminology, while there are enough references to statutory and case law to make it useful for lawyers. The author is a practicing attorney. After an introduction to the American legal system, the author covers a myriad of topics related to the subject: medical record entries, managed care issues, consent to treatment, access, confidentiality, reporting, disclosure, documentation, legal admissibility of records, improper disclosure, risk management and quality review, and computerized medical records. There is a separate chapter on HIV issues. The references are excellent, and the index is good... With this book the author offers a creditable exposition of the law in the area." - Jay Gold, MD, JD, MPH, Doody Review Services

The American Health Information Management Association (AHIMA) is the community of professionals engaged in health information management, providing support to members and strengthening the industry and profession. A world in which the public values the contribution of health information management professionals and the American Health Information Management Association, in the advancement of health through quality information: 1) Provides career, professional development and practice resources; Sets standards for education and certification; and, Advocates public policy that advances HIM practice. AHIMA fosters the professional development of coding professionals through advocacy, education, certification, and lifelong learning opportunities.

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