Health Record Policies

Health Record Policies

Health Record Policies 

Health Record Policies 

Evaluate the two policies in the attached “Health Record Policies” by doing the following:
Discuss what information should be included in an addendum pertaining to a shadow chart.

Generally, an addendum includes amendments or corrections in the primary medical records.This must bear the client’s signature, the amendment date and the amendments themselves. This avails the information that was missing at time of original entry.

Discuss how information technology staff can help decrease incidents of security breaches.

Security breaches especially related to data cause negative consequences for healthcare institutions, their clients and employees. The information technology staff should take preventive measures to avoid this. Encrypting confidential data is essential. All computers in the organization must have password protection. Also a backup of all data must be kept to avoid loss of data in case of data loss. Thirdly, controls must be placed on data access and storage to avoid unauthorized access. Disposal of outdated data and equipment should be done carefully, and there should be regulation on use of laptops and other portable storage media and devices (Pendrak & Ericson, 1998).

Discuss one situation from Montana Code 41-1-402 (2a through 2d) that may result in criminal liability to the organization if not followed.

A situation that may result in criminal liability for a healthcare institution is if for example an abortion is procured on a minor from a stable family and under the care of her parents without the parent’s consent.

Summarize how HIPAA defines criminal liability.

HIPAA has put a penalty for any unauthorized access to a patient’s medical records with or without knowledge of this law. Employees in healthcare institutions can also be charged with breaching the confidentiality of patients without authority to do so. 
Explain which part of 2a through 2d of Montana Code 41-1-402 would directly impact actions of clinical staff.
Part 2 (d) would impact actions of the clinician. If a minor needs treatment for STDs, drug and substance abuse, then if the clinician accepts to offer treatment, they are also mandated to offer counseling the minor or refer them to a counselor.

 Discuss one situation from Montana Code 50-16-603x (1 through 7) specific to health record identification that may result in a legal claim against the organization if not followed.

 If a healthcare institution uses pictures of their former patients for its advertisement on the media without written consent from the former clients.
Develop a confidentiality policy statement (suggested length of 1–2 sentences) using either Montana Code 41-1-402 or Montana Code 50-16-603.

Disclosure of a patient’s presence: This should not be disclosed to unauthorized parties, even in a manner that would reveal nature of disease without the consent of the patient as it will be a breach of confidentiality. 

Compare three points in the Montana codes to HIPAA laws as they refer to release of information.

50-16-542. 1(a) Release of information will be denied if the healthcare provider thinks it will cause negative effects on the recipient. 50-16-542. 1(c) if the information will cause danger to the recipient’s safety and 50-16-542. 2(a) if the minor has a mental condition. All these show that information can only be released if it will not cause any adverse effects on the patient.

Develop a release of information policy statement (suggested length of 1–2 sentences) using either Montana Code 50-16-541 or Montana Code 50-16-542 for a policy book.

Releasing information of patient over the phone of fax: This is not encouraged as the there is no evidence provided to show that the caller or fax destination are eligible recipients of the patient information.


Pendrak, R. F., & Ericson, R. P. (1998). Information technologies need to protect patient confidentiality.Healthcare Financial Management, 52(10), 66-8. Retrieved from;

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