Legal and Ethical Dimensions of Negligence and Health Records

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!

Here’s a step-by-step approach you can use to organize and complete your paper effectively:

Step 1: Introduction

• Start with a short introduction that explains the importance of negligence, proper health record management, and legal/ethical issues in healthcare.

• End your introduction with a clear thesis statement, for example:
  “This paper explores the four elements of negligence, the role of health records, the concept of e-discovery, advance directives, and applies legal concepts to a malpractice case scenario.”

Step 2: The Four Elements of Negligence

• Define negligence in healthcare.

• Explain each of the four elements: duty of care, breach of duty, causation, and damages.

• Use a real-world healthcare example to illustrate.

Step 3: Purposes of the Health Record

• Discuss clinical purposes (continuity of care, treatment planning).

• Discuss legal purposes (evidence in court, malpractice defense).

• Include financial (billing/reimbursement) and compliance purposes.

• Highlight research and education uses.

Step 4: E-Discovery and the HIM Professional’s Role

• Define e-discovery in legal terms.

• Explain its application to healthcare (EHRs, audit trails, metadata).

• Describe the specific roles HIM professionals play (record retention, privacy, compliance, litigation support).

Step 5: Living Will vs. Durable Power of Attorney

• Define each document.

• Compare their scope and purpose.

• Explain the key difference (treatment-specific vs. decision-maker specific).

• Provide a brief healthcare scenario to show practical use.

Step 6: Case Application – Risk Management Scenario

• Restate the malpractice scenario in your own words.

• Apply legal concepts:

  • Why the record may not be admissible (late dictation, compliance failures).

  • How negligent supervision by the organization may apply.

• Provide a balanced conclusion (physician at fault, but organization may share liability).

Step 7: Conclusion

• Summarize key takeaways.

• Reinforce the importance of accurate documentation, compliance, and ethical practices in reducing legal risks.

Step 8: References

• Include at least 3–5 scholarly sources in APA 7th edition format.

• Use peer-reviewed journals, law/healthcare textbooks, and credible websites.

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