Minnesota Legal Reference Manual
The Minnesota Legal Reference Manual is a manual containing information on key aspects of the Health Information Management (HIM) world in Minnesota. There are currently 14 Chapters that address a variety of HIM related topics. While focusing primarily on the legal issues within HIM, the manual also includes best practice guidelines for the handling of medical information.
The manual is reviewed continuously for updates and revisions by the Legal Reference Manual Committee as well as a team of legal professionals. The Legal Manual Committee is made up of HIM professionals from different facilities and companies across the state, each bringing their own expertise and experience to the table. This creates a wide body of knowledge from all areas of HIM.
Subscription
Current subscribers need to login in order to access the manual. Not a subscriber? Subscribe today! If you are a subscriber and need assistance, please contact us.
Access Instructions
When you order online, you will be asked for the names and email addresses for each of the subscribers. Once your payment has been received, access instructions will be emailed to each of these email addresses within two business days from receipt of payment.
For assistance accessing the online subscription, please contact us.
Table of Contents
Chapter 1: Legal Health Records
- Overview
- 1. Purpose
- 2. Ownership
- 3. Legal Health Record Components
- 4. Maintaining the Legal Health Record
- 5. Health Care Directives
- 6. Secondary Health Care Records
- 7. Health Information from Other Health Care Providers
- 8. Facility Closing, Sale, Mergers, Retirement or Death of a Physician
- 9. Retention of Health Care Records
Chapter 2: American Recovery and Reinvestment Act of 2009 (ARRA) & Health Information Technology for Economic Health (HITECH) Act
- 1. Overview
- 2. HITECH Act
- 3. Minnesota HITECH Updates
- 4. Security Breach Notification – Effective September 15, 2009
- 5. Application of HIPAA Privacy and Security Requirements to Business Associates
- 6. Restrictions on Certain Disclosures: Out of Pocket Payments
- 7. Marketing, Fundraising and Sale of PHI
- 8. Accounting of Disclosures
- 9. Resources
Chapter 3: Required/Voluntary Reporting
Chapter 4: Legal Proceedings/Requests
- 1. Overview
- 2. Geographic Restrictions/Jurisdiction of Requests
- 3. State Statutes and Rules of Judicial Procedures
- 4. Subpoenas
- 5. Communications with Patients
- 6. Search Warrants
- 7. Tracking Legal Requests for Accounting of Disclosures
- 8. Electronic Discovery and Disclosure
- 9. Preparation/Delivery of the Health Care Record
- 10. Legal Requirements for Metadata
- 11. Code of Federal Regulations (21 CFR Part 11)
Chapter 5: Disclosure Management: Release of Information and Patient Access
- 1. Overview
- 2. Review of Laws and Regulations
- 3. Access and Withholding of Patient Information
- 4. General Considerations for Disclosure to Others
- 5. Considerations for Types of Requesters
- 6. Considerations for Types of Information
- 7. Requirements for a Valid Authorization
- 8. Designated Record Set/Legal Health Record
- 9. Processing Requests for Disclosure/Release of Information
- 10. Recording and Documenting Disclosures
- 11. Retention of Authorization Forms
- 12. Charges for Retrieval/Copies
Chapter 6: Consents
- 1. Definitions
- 2. Authorization vs. Consent
- 3. Requirement for Consent for Treatment
- 4. Who Can Consent
- 5. Legal Documents
- 6. Incompetent Individuals
- 7. Individuals Who Physically Cannot Sign
- 8. Specific Informed Consents Required by Minnesota Law
- 9. Body Removal
- 10. Emergency Situations
- 11. Good Samaritan Law
Chapter 7: Behavioral Health Care Records
Chapter 8: Long Term Care
- 1. Definitions
- 2. Overview
- 3. How to Use this Section
- 4. Health Information Management Service
- 5. Confidentiality of Medical Records and Information
- 6. Medical Record Guidelines
- 7. Abbreviations
- 8. Master Resident Record
- 9. Medical Record Contents
- 10. Social Services
- 11. Comprehensive Resident Assessment
- 12. MDS Retention Period
- 13. Automated Data Processing Requirement
- 14. Comprehensive Plan of Care
- 15. Telephone and Electronic Orders
- 16. Admission Orders and Physician Evaluations
- 17. Frequency of Physician Evaluation
- 18. Physician Services
- 19. Medical Information for Clinical Record
- 20. Documentation of Routine and Emergency Oral Health Services
- 21. Administration of Medications
- 22. Disposition of Medications
- 23. Transfer, Discharge and Death
- 24. Quality Measures and Indicators
- 25. Retention, Storage and Retrieval
- 26. Computerization
- 27. Penalties for Clinical Records Rule Violation
Chapter 9: Home Care/Hospice
- Overview
- 1. General Rules, Regulations and Definitions
- 2. Content of Home Health Care Records
- 3. Content of Hospice Records
- 4. Minnesota Rules and Regulations for Home Care Organizations
- 5. Medicare Requirements For Home Health Agencies
- 6. Minnesota Rules and Regulations For Hospice Organizations
- 7. Medicare Requirements For Hospice
Chapter 10: Ambulatory Care Health Records
Please note that the MHIMA Legal Manual Committee has, upon careful review, decided to delete this chapter.
The information is embedded in others within the manual.
Chapter 11: Risk Management
Chapter 12: Health Information Accountability and Portability Act (HIPAA)
- Overview
- 1. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- 2. Centers For Medicare And Medicaid Services (CMS) Fraud And Abuse
- 3. Transaction and Code Sets (TCS)
- 4. Security
- 5. Privacy
- 6. Notification in the Case of Breach of Unsecured PHI
- 7. Enforcement of Privacy Regulations
- 8. Filing a Privacy Complaint
- 9. Identity Theft
- 10. Law Enforcement
- 11. Patient Rights
- 12. Pre-emption of State Law