Revised 08/2025
HIM 226 - Legal Aspects of Health Record Documentation (2 CR.)
Course Description
Presents the legal requirements associated with health record documentation. Emphasizes the policies and procedures concerning the protection of the confidentiality of the patient's health record. Lecture 2 hours per week.
General Course Purpose
The student will learn to evaluate the health record as a legal document with a special emphasis placed on the policies and procedures concerning the release of medical information.
Course Prerequisites/Corequisites
HIM program placed students only:
Prerequisites/corequisites are BIO 142, HIM 110, HIM 130, HIM 141, HIM 142, HIM 220 or permission of instructor. The course will be offered to any student who meets the prerequisites/co-requisites and is program placed in the Health Information Management (HIM) program.
Course Objectives
Upon successful completion of the course, students will be able to:
- Differentiate between types of law (public, private, civil, criminal, tort, contract).
- Identify sources of law and their impact on health care operations and documentation.
- Describe the legislative process and the roles of government branches in lawmaking.
- Compare federal and state court jurisdictions.
- Outline the steps in civil litigation, including discovery, trial, and appeal.
- Interpret legal instruments such as subpoenas, court orders, and writs.
- Describe the legal uses, authorship, correction, and retention of health records.
- Evaluate the admissibility of health records in legal proceedings.
- Explain the responsibilities of health information professionals in legal compliance.
- Define and distinguish between negligence, malpractice, and intentional torts.
- Identify legal defenses and risk management strategies in health care.
- Explain the role of incident reports and peer review protections.
- Differentiate between ethics, morals, values, and law.
- Apply ethical theories and decision-making models to health care dilemmas.
- Analyze ethical issues related to life, death, confidentiality, and emerging technologies.
- Explain the legal basis for privacy and confidentiality, including physician-patient privilege.
- Discuss the handling of sensitive information (e.g., HIV/AIDS, mental health, genetic data).
- Compare privacy statutes with open records laws.
- Define ownership and patient rights regarding health records.
- Differentiate between consent and authorization for information release.
- Describe redisclosure rules, minimum necessary standards, and IRB roles.
- Identify legal requirements for substance abuse, mental health, and home health records.
- Explain procedures for handling subpoenas and court orders in specialized contexts.
- Discuss legal and ethical considerations in HIV/AIDS testing and disclosure.
- Describe legal standards for EHR creation, storage, and security.
- Evaluate the business record exception and its application to EHRs.
- Identify risks and safeguards related to EHRs, telemedicine, and cybersecurity.
- Define fraud and abuse and identify relevant laws and enforcement agencies.
- Explain the components and importance of compliance programs in health care.
- Define employment relationships and the at-will doctrine.
- Identify employee rights and workplace protection laws.
- Analyze the ethical and legal considerations in human resource management.
Major Topics to Be Included
- Foundations of health care law
- Judicial system and legal procedures
- Health records and legal documentation
- Health information in legal contexts
- Liability and risk management
- Ethics in health care
- Privacy, confidentiality, and consent
- Access, disclosure, and ownership of health information
- Specialized legal Issues in health information
- Electronic Health Records (EHRs) and technology
- Health care fraud, abuse, and compliance
- Employment law in health care