Course Number and Title: HIM 130 Legal Aspects of Health Information Management
This course focuses on legal and regulatory issues in healthcare with emphasis on their application to healthcare information services and documentation of care. Students explore the rights and responsibilities of providers, employers, payers, and patients in a healthcare context. Topics include civil liability terminology, judicial and legislative processes, legal and regulatory issues pertaining to confidentiality of information, and laws and regulations addressing release of information and retention of records.
Allied Health/Science Department Policy Manual
HIM Program Policy Manual
- Apply legal principles to the collection and maintenance of health data. (CCC 1; HIM PGC 3, 5)
- Apply legal, regulatory, and accreditation standards to HIM practice. (CCC 1; HIM PGC 3, 5)
- Analyze policies and procedures to comply with legal, regulatory, accreditation, and professional standards. (CCC 1, 2; HIM PGC 3, 5)
- Interpret local, state, federal, and professional regulations and guidelines to support human resource, strategic and organizational needs. (CCC 1, 2; HIM PGC 2, 3)
- Apply and promote ethical standards within the practice of health information management. (CCC 4; HIM PGC 6)
See Core Curriculum Competencies and Program Graduate Competencies at the end of the syllabus. CCPOs are linked to every competency they develop.
Upon completion of this course, the student will:
- Apply legal principles to the collection and maintenance of health data.
- Identify a complete health record according to organizational policies, external regulations, and standards.
- List the purposes of the health record.
- Identify the major content areas of the health record.
- Explain the structure of a healthcare organization.
- Explain the medical staff organization of a healthcare organization and its legal issues, provider contracts with facilities and bylaws.
- Apply policies and procedures to ensure the accuracy and integrity of health data:
- Describe the purpose and contents of medical staff and hospital bylaws.
- Explain the use of medical staff and hospital bylaws by health information practitioners.
- Explain the legal and regulatory issues pertaining to nursing practice.
- Explain the legal and regulatory issues pertaining to allied health professionals.
- Explain the legal and regulatory issues pertaining to information management.
- Apply legal, regulatory, and accreditation standards to HIM practice.
- Describe legal terminology and requirements that apply to the following:
- Sources of law
- Levels of the United States government
- Branches of the United States government
- Structure and organization of the United States judicial system
- Legal proceedings before trial
- Roles of court officers
- Trial process
- Non-government lawmaking bodies
- Identify the use of legal documents.
- Identify the key federal laws that apply to healthcare.
- Explain the difference between tort law and criminal law.
- Describe the role of advanced directives in treatment and end-of-life healthcare decisions.
- Identify the components of a valid subpoena.
- Discuss the various types of requests for access, use, and/or disclosure of patient information and steps for handling the requests.
- Request for restriction.
- Request for amendment.
- Request for accounting of disclosure.
- Requests for confidential communication.
- Business associate agreement.
- Disclosures for law enforcement.
- Subpoenas, court orders, and search warrants.
- Patient request for release of information.
- Release with and without patient consent.
- Explain the various types of consent forms.
- Explain patient verification procedures.
- Describe preventive, detective, and corrective controls surrounding medical identify theft.
- Describe the Notice of Privacy Practices.
- Describe the process for disclosing health information for federal and state disability determination.
- Explain patient rights and responsibilities.
- Describe retention and destruction policies for health information.
- Apply confidentiality, data privacy and security measures, and policies and procedures to protect the internal and external use and exchange of electronic health information.
- Apply policies and procedures surrounding issues of access and disclosure of protected health information.
- Discuss the issues surrounding ownership of health information.
- Distinguish express and implied consent.
- Explain the various privacy issues related to minors when parent/legal guardian authorization is required.
- Discuss the obligations of the healthcare workforce regarding access to and disclosure of health information.
- Explain the issues surrounding the access, use, and disclosure of genetic information.
- Explain access and disclosure rights regarding adoption information and adopted individuals.
- Explain access and disclosure rights of competent and incompetent adult patients.
- Discuss the reimbursement and fee structure for copying health information.
- Summarize the issues related to managing the release of information in terms of verification of requester, determining if the request is legitimate, accounting for disclosures, and refusing to disclose information.
- Discuss the statutory requirements that provide employees’ rights to their safety and health records.
- Use software in the completion of HIM processes.
- Describe the requirements for maintaining user access logs for electronic versus paper-based systems.
- Describe the methods for maintaining user access logs and disclosure of identifiable patient data.
- Demonstrate how to maintain user access logs/systems to track access to and disclosure of identifiable patient data.
- Describe legal terminology and requirements that apply to the following:
- Analyze policies and procedures to comply with legal, regulatory, accreditation, and professional standards.
- Describe the purpose and goals of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules.
- Explain the impact of the Health Information Technology for Economic and Clinical Health (HITECH) Act on HIPAA Privacy and Security Rules.
- Discuss state and federal laws designed to protect sensitive health information related to behavioral healthcare, substance abuse, and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).
- Collaborate with staff in preparing the organization for accreditation, licensure, and/or certification.
- Adhere to the legal and regulatory requirements related to the health information management.
- Identify potential abuse or fraudulent trends through data analysis.
- Interpret local, state, federal, and professional regulations and guidelines to support human resource, strategic and organizational needs.
- Interpret compliance with local, state, federal labor regulations.
- Adhere to work plans, policies, procedures, and resource requisitions in relation to job functions.
- Self-assess cultural competence, including assumptions, biases, and stereotypes.
- Identify behaviors that support a culture of diversity.
- Apply and promote ethical standards within the practice of health information management.
- Describe the role of professional codes of ethics in protecting health information.
- Given specific scenarios, explain how ethical standards are applied and promoted in health information.
- Identify a breach of healthcare ethics as it applies to access and disclosure of health information.
Students must demonstrate proficiency on all CCPOs at a minimal 75 percent level to successfully complete the course. The grade will be determined using the Delaware Tech grading system:
Students should refer to the Student Handbook for information on the Academic Standing Policy, the Academic Integrity Policy, Student Rights and Responsibilities, and other policies relevant to their academic progress.
Calculated using the following weighted average
Percentage of final grade
Class Participation (formative)
Case Studies (summative)
Lab – Neehr Perfect Activities (summative)
Exams 1, 2, 3, 4 (summative) (equally weighted)
- Apply clear and effective communication skills.
- Use critical thinking to solve problems.
- Collaborate to achieve a common goal.
- Demonstrate professional and ethical conduct.
- Use information literacy for effective vocational and/or academic research.
- Apply quantitative reasoning and/or scientific inquiry to solve practical problems.
- Synthesize knowledge of medical sciences, clinical classification systems, vocabularies, and terminologies to effectively use, apply, and interpret health data.
- Analyze data to identify trends through the use of health information technologies
- Apply legal, regulatory, privacy, and security standards to employ policies and procedures for health information collection, access, and disclosure.
- Synthesize knowledge of health data and payment methodologies to evaluate the efficiency and effectiveness of revenue cycle processes.
- Interpret regulatory, coding, legal, and clinical documentation standards to develop, implement, and evaluate compliance.
- Consistently demonstrate leadership through the appropriate interpretation and evaluation of professional behaviors and ethical standards.
The College is committed to providing reasonable accommodations for students with disabilities. Students are encouraged to schedule an appointment with the campus Disabilities Support Counselor to request an accommodation needed due to a disability. A listing of campus Disabilities Support Counselors and contact information can be found at the disabilities services web page or visit the campus Advising Center.