Question

Subpoena Policy and Procedure

From time to time, medical records will be subpoenaed for court cases. Therefore, it is important to know the policy that details how to respond to a subpoena for a patient’s medical records. Please answer the following: (please refer to Chapter 5 – Legal Aspects of Health Insurance and Reimbursement)

• How do you handle legal documents?

I have looked through my textbook and can not find anything on Subpoena Policy and Procedures... Help :(

Answer 1

As you said me too haven't seen about "Subpoena Policy and Procedure" in text books. So here I done some online research about this and find the following answers for your question.

Subpoena Policy and Procedure

A legal document, issued in the course of a lawsuit, which is used to compel attendance of a witness at a judicial proceeding or a deposition. Court order/court subpoena. An official legal order that compels a witness to appear in court and to provide testimony or produce records in a particular case. Subpoenas can be issued to compel a person to give evidence in court, produce documents to the court or both. ... Even if a patient does not consent to the disclosure, a practitioner who is issued with a subpoena for production of a patient's medical record must provide the requested documents to the court.

Determine How to Respond to, or Challenge, the Third-Party Subpoena

• Comply with the subpoena and provide the requested documents.
• Object to the subpoena.
• Move to quash the subpoena.
• Contact the party that served the subpoena to attempt to resolve the requests informally.
• Contact the adverse party.

Question : How do you handle legal documents?

Answer :

The two most common ways to store your legal documents are to keep them in paper file and store them in filing cabinets, and to store them digitally on your computer. These are both great ways to keep everything managed, but depending on your office one may work better than the other.

Drafting Legal Documents:

• Plan Out the Document Before You Begin
• Write with Clear and Concise Language
• Ensure the Correct Use of Grammar.
• Be as Accurate as Possible.
• Make Information Accessible.
• Ensure All Necessary Information Is Included.
• Always Use an Active Voice.
• Pay Attention to Imperatives.
• Use Direct Language
• Use Consistent Descriptions

Examples of documentation found in the legal health record:

• Records of history and physical examination.
• Multidisciplinary progress notes/documentation.
• Immunization record.
• Problem list.
• Medication profile / Physician Orders and Renewals.
• Consent for treatment forms.
• Consultation reports.

Storage of legal documents ;

• We recommend that medical records and PHI stored in hallways that are accessible by unauthorized individuals should be in locked cabinets.
• No open shelves in a patient or research subject area.
• No open shelves in a hallway that allows access to individuals not authorized to access those medical records and PHI.
• Federal law mandates that a provider keep and retain each record for a minimum of seven years from the date of last service to the patient.