Legal and Ethical Issues in Healthcare Documentation and Negligence

1. Explain the four elements of negligence that must be present in order for a plaintiff to recover damages?
2. Discuss the purposes for which the health record is maintained within a healthcare organization.
3. Explain the concept of e-discovery and discuss the role of health information management professionals in the e-discovery process.
4. What are the differences between a living will and a durable power of attorney for healthcare?
5. The corporate director of risk management is asked to review a patient’s health record in preparation for legal proceedings for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longstanding history of being non-compliant with the organization’s record completion policies, and previous concerns regarding this physician’s record maintenance practices had been reported to the organization’s credentialing committee.
   1. Apply appropriate legal concepts to demonstrate why this health information may not be admissible in court.
   2. What judgment, if any, regarding negligence could be made against the organization?

Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

Step 1: Understand the Task

This assignment combines short-answer essay questions with a case analysis. You need to:

1. Explain legal concepts (negligence, living will vs. durable power of attorney, e-discovery).

2. Discuss the functions of health records.

3. Apply legal principles to a realistic malpractice case scenario.

Your paper should be well-structured, using clear headings or sections for each question.

Step 2: Structure Your Paper

Here’s a suggested format:

1. Introduction (100–150 words)

   • Briefly introduce the role of legal and ethical principles in healthcare.

   • State that the paper will cover negligence, health records, e-discovery, advance directives, and case analysis.

2. Section 1: Four Elements of Negligence (200–250 words)

   • Duty of Care: The physician must owe a duty to the patient.

   • Breach of Duty: The provider fails to meet the expected standard of care.

   • Causation: A direct link between the breach and the patient’s injury.

   • Damages: The patient suffered actual harm or loss.

   • Provide a short example of how these apply in healthcare malpractice.

3. Section 2: Purposes of the Health Record (150–200 words)

   • Clinical communication and continuity of care.

   • Legal evidence in malpractice claims.

   • Billing and reimbursement documentation.

   • Accreditation, quality improvement, and research.

4. Section 3: E-Discovery in Healthcare (150–200 words)

   • Define e-discovery: the process of identifying, collecting, and producing electronically stored information for legal cases.

   • Role of HIM professionals: ensuring integrity, accuracy, and legal compliance of records; assisting legal teams with proper documentation retrieval.

5. Section 4: Living Will vs. Durable Power of Attorney (150–200 words)

   • Living Will: A document stating a patient’s wishes about life-sustaining treatments.

   • Durable Power of Attorney for Healthcare: Appoints a trusted person to make healthcare decisions if the patient becomes incapacitated.

   • Highlight key differences (scope, flexibility, decision-making authority).

6. Section 5: Case Analysis (300–400 words)

   • Admissibility of Records: The delayed dictation (95 days after procedure) undermines the reliability of records. Courts require timely, accurate entries; late entries may be ruled inadmissible.

   • Physician’s Non-Compliance: Demonstrates negligence in documentation standards and could weaken defense.

   • Organizational Liability: The hospital may face negligent credentialing or failure to enforce compliance since prior concerns about the physician’s practices were known but not effectively addressed.

7. Conclusion (100–150 words)

   • Summarize key legal principles.

   • Reinforce the importance of proper documentation and risk management in healthcare.

Step 3: Format Your Paper

• Use APA, MLA, or Chicago style (choose one and stay consistent).

• Include proper in-text citations and a reference list.

• Standard formatting: Times New Roman, 12-point font, double-spaced, 1-inch margins.

Step 4: Review Before Submission

• Check grammar and spelling (remember: 5 errors = point deduction).

• Ensure all questions are fully answered.

• Proofread to make sure your answers are concise, clear, and supported by examples.

Helpful Resources:

• Cornell Law: Negligence Overview

• AHIMA: E-Discovery and HIM Professionals

• Mayo Clinic: Living Will vs. Power of Attorney

• Purdue OWL: APA Style Guide

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