Table of contents for Ethical challenges in the management of health information / edited by Laurinda B. Harman.

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Counter
Ethical Challenges in the Management of Health Information, Second Edition
Laurinda B. Harman, PhD, RHIA
PART 1 Summary 
Chapter 1 Professional Values and the Code of Ethics
Laurinda B. Harman, PhD, RHIA
Virginia L. Mullen, RHIA
Learning Objectives 
Abstract 
Ethical Dilemmas For The HIM Professional
The Health Information System: Then And Now
Health Care System
Healthcare Documentation
Access to and Release of Information
Coding and Reimbursement
Technology
Role Of The HIM Professional
Professional Code Of Ethics
Professional Values
Patients and the Healthcare Team 
Employer
Public Interest
Professional Associations and Oneself
Building An Ethical Health Information System
Intersection Of HIM and Ethics
Key Terms 
Chapter Summary
References 
Appendix 1-A: 1957 Code of Ethics for the Practice of Medical Record Science
Appendix 1-B: 1977 American Medical Record Association Bylaws and Code of Ethics 
Appendix 1-C: 1988 American Medical Record Association Code of Ethics and Bylaws
Appendix 1-D: 1998 American Health Information Management Association Code of Ethics and Bylaws
Appendix 1-E: 2004 American Health Information Management Association
Code of Ethics
Chapter 2	Ethical Decision-Making Guidelines And Tools
Jacqueline J. Glover, PhD
Learning Objectives
Abstract
Scenario 2-A: Documentation And DRG Assignment
What Is An Ethical Issue?
Why Is It Important To Identify And Address Ethical Issues?
But You Can¿t Teach Ethics, Can You?
The Process Of Ethical Decision-Making
Justification In Ethical Reasoning: How Do You Know What Is Best?
Classic Ethical Theories
Utilitarian Theories
Deontological Theories
Applications Of More Than One Theory
Current Ethical Approaches
Analysis of Principles
Analysis Of Rights
Ethics of Care
Virtue-Based Ethics
The Bioethicist¿s Toolbox
Moral Distress
Scenario 2-B: Retrospective Documentation To Increase Reimbursement
Ethics Resources
Conclusion
Key Terms 
Chapter Summary
References
Ethical Decision-Making Matrices: 
	-Scenario 2-A: Documentation and DRG Assignment
	-Scenario 2-B: Retrospective Documentation to Increase Reimbursement
Appendix 2-A: Blank Ethical Decision-Making Matrix
Chapter 3	Privacy and Confidentiality
Laurie A. Rinehart-Thompson, JD, RHIA, CHP
Laurinda B. Harman, PhD, RHIA
Learning Objectives
Abstract 
Scenario 3-A: Family and Friends: Should I Tell?
Privacy And Confidentiality
Release of Information
HIPAA Privacy Rule
Requirements for patient authorization
Protection of patient information
Protection of patient information
		Patient Authorization Required
		Patient Authorization Not Required
Blanket Authorizations 
Patient Concerns
Patient Concerns
Conclusion
Key Terms
Chapter Summary
References 
Glossary of Terms 
Ethical Decision-Making Matrix 
	-Scenario 3-A: Family and Friends: Should I Tell?
	
PART II Summary
Chapter 4	Compliance, Fraud, and Abuse
Laurie A. Rinehart-Thompson, JD, RHIA, CHP
Ann Hubbuch, JD, RHIA
Learning Objectives 
Abstract 
Scenario 4-A: Documentation Does Not Justify Billed Procedure
The Traditional Regulations Guiding Us
False Claims Act
Qui Tam Statutes
Qui Tam Statutes
Antikickback Statutes
Antireferral Statutes: Stark I and II
¿Safe Harbors¿ and Stark Exceptions
Mail and Wire Fraud
More Recent Regulations That Guide Us
HIPAA Administrative Simplification Standards
Security Standards
Privacy Standards
Enforcement Programs
False Claims Penalties
Roles for HIM Professionals
Compliance Programs To Prevent Fraudulent Behaviors
Dilemmas In Practice
Disclosure of Health Information
Scenario 4-B: Accepting Money for Information
Fraudulent Documentation Practices
Retrospective Medical Record Analysis
Scenario 4-C: Retrospective Documentation To Avoid Suspension
Scenario 4-D: Coder Assigns Code Without Physician Documentation
Coding Turnaround Time
Conclusion
Key Terms 
Chapter Summary
References
Ethical Decision-Making Matrices:
	-Scenario 4-A: Documentation Doesn¿t Justify Billed Procedure	
	-Scenario 4-B: Accepting Money for Information
	-Scenario 4-C: Retrospective Documentation to Avoid Suspension
-Scenario 4-D: Coder Assigns Code Without Physician Documentation
Chapter 5	Clinical Code Selection and Use
Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P
Rita A. Scichilone, MHSA, RHIA, CCS, CCS-P, CHC
Learning Objectives
Abstract 
Scenario 5-A: Coding and Inappropriate Level of Service
HIPAA and Billing Activities
Ethical Approaches To Coding Situations
	Utilitarian Approaches
	Deontological Approaches
Core Competencies and Credentials
Applying The AHIMA Standards Of Ethical Coding
Ethical Dilemmas For The Coding Professional
Scenario 5-B: Discovering Misrepresentation in Physician Documentation
Scenario 5-C: Miscoding To Avoid Conflicts
Scenario 5-D: Discovering Miscoding by Other Staff
Scenario 5-E: Lacking the Tools To Do One¿s Job
Scenario 5-F: Being Required by the Employer To Engage in Negligent Coding Practices
Scenario 5-G: Supporting Application Software that Facilitates Questionable Results
Professional Practice Solutions
	Coding Compliance Plans
	Established Coding Guidelines
	Responses to Fraudulent Activity
The Future Of Coding
Key Terms 
Chapter Summary
References 
Ethical Decision-Making Matrices
	-Scenario 5-A: Coding Inappropriate Level of Service
	-Scenario 5-B: Discovering Misrepresentation in Physician Documentation
	-Scenario 5-C: Miscoding to Avoid Conflicts
	-Scenario 5-D: Discovering Miscoding by Other Staff
	-Scenario 5-E: Lacking the Tools to Do One¿s Job
-Scenario 5-F: Being Required by the Employer to Engage in Negligent Coding Practices
-Scenario 5-G: Supporting Application Software that Facilitates Questionable Results
Chapter 6	Quality Review
Patrice L. Spath, BA, RHIT
Learning Objectives
Abstract 
Quality Management
QM Ethical Issues Facing Him Professionals
Ethical Standards Affecting QM Activities
Patient Safety and Professional Ethics
Inconsistencies among Professional Conduct Codes
Organizational Values
Personal Convictions
Making Ethical Decisions
QM Situations That Raise Ethical Questions
Scenario 6-A: Inaccurate Performance Data
Scenario 6-B: Home Health Care and Central-line Infections
Scenario 6-C: Failure To Check Physician¿s Licensure Status
Scenario 6-D: Hiding Incomplete Medical Records
Scenario 6-E: Audit Results Indicate Inappropriate Health Care
Enabling Ethical Conduct
	Role of the Profession
Role of the Employer
Conclusion: Facing QM Ethical Dilemmas
Key Terms 
Chapter Summary
References 
Scenarios¿Survey Results and Ethical Decision-Making Matrices
	-Scenario 6-A: Inaccurate Performance Data
	-Scenario 6-B: Home Health Care and Central-line Infections
-Scenario 6-C: Failure To Check Physician¿s Licensure Status
-Scenario 6-D: Hiding Incomplete Medical Records
-Scenario 6-E: Audit Results Indicate Inappropriate Health Care
Chapter 7	Research and Decision Support
Merida L. Johns, PhD, RHIA
J. Michael Hardin, PhD
Learning Objectives
Abstract
Scenario 7-A: Designing a Survey To Bias the Results
Roles Of The RS and DSS
Ethical Responsibilities Of The RS and DSS
Ensuring Data Integrity and Confidentiality
Human Subject Research
Maintaining and Enhancing Professional Competence
Conclusion
Key Terms 
Chapter Summary
References 
Ethical Decision-Making Matrix
	-Scenario 7-A: Designing a Survey To Bias the Results
Chapter 8	Public Health
Babette J. Neuberger, JD, MPH
Learning Objectives
Abstract 
Scenario 8-A: Reporting HIV Status
Public Health: An Overview
The Evolution of Public Health and Governmental Access to Private Medical Information
Sexually Transmitted Disease (STD) Contact Tracing and Partner Notification
State Use of Health Data for Planning Purposes
Ethical Challenges In Public Health
When the Public¿s Right To Know Conflicts with the Individual¿s Right to Privacy
Scenario 8-B: When Duty to One¿s Employer Conflicts with a Duty Owed to the Public
The HIM Professional¿s Role And Responsibility As An Advocate
A Reciprocal Duty Owed Society
Superior Knowledge
An Unambiguous Duty To Protect Patient Privacy
Resources for Advocacy
Emerging Issues: Bioterrorism and Global Infections
Scenario 8-C: The Terrorism Preparedness Act 
Conclusion
Key Terms 
Chapter Summary
References 
Ethical Decision-Making Matrices
-Scenario 8-A: Reporting HIV Status
-Scenario 8-B: When Duty to One¿s Employer Conflicts with a Duty Owed to the Public
-Scenario 8-C: The Terrorism Preparedness Act. See text. No decision-making matrix for this scenario. 
Chapter 9	Managed Care: Lessons of Integration
Ida Critelli Schick, PhD, MS, FACHE
Learning Objectives
Abstract 
Scenario 9-A: Complexity of Choosing a Managed Care Plan
Growth Of Managed Care
Managed Care Strategies
Pricing
Access
Quality
The Role Of Information And Him Professionals In A Managed Care Environment
Ethical Dilemmas For Him Professionals
Limiting Access to Information by Managed Care Organizations
Scenario 9-B: Provision of Information by Physician Practices
Access to Information about Patients
HIM Professionals in MCOs
Scenario 9-C: HIM Professionals in Provider Organizations
Policies For Which The HIM Professional Can Advocate
Managed Care Plans
Provider Organizations
Federal Legislation
Conclusion
Key Terms
Chapter Summary
References 
Ethical Decision-Making Matrices
-Scenario 9-A: Complexity of Choosing a Managed Care Plan
-Scenario 9-B: Provision of Information by Physician Practices
-Scenario 9-C: HIM Professionals in Provider Organizations
PART III Summary
Chapter 10	Clinical Care: End of Life
James F. Tischler, M.D.
Learning Objectives 
Abstract 
Scenario 10-A: Bad News
Aging, Frailty And Information Ethics
Evolution Of Autonomy
Cultural Influences On Autonomy
Physician Bias & Equity: A Systems Issue
Scenario 10-B: Treatment Choices
Information Across A Healthcare Continuum
Treatment Goals And Beneficence
Scenario 10-C: Advance Care Planning
Advance Care Planning: An Opportunity
The Meaning Of ¿Terminal¿
Advance Care Planning And Law
Scenario 10-D: Palliative Care
Managing Pain
Ethics Committees
Palliative Care
Emerging Issues
Chapter Summary
Glossary
Ethical Decision-Making Matrices
	-Scenario 10-A: Bad News
	-Scenario 10-B: Treatment Choices
	-Scenario 10-C: Advance Care Planning
	-Scenario 10-D: Palliative Care
References (Footnotes) 
Chapter 11	Electronic Patient Record
Mary Alice Hanken, PhD, CHP, RHIA
Gretchen Murphy, MEd, RHIA
Learning Objectives 
Abstract 
Scenario 11-A: Patient Record Integrity and System Security
EHR Systems: Functions And Expected Features
EHR Systems in the 21st Century
EHR Technology And Ethical Issues
Patient Privacy
Data Quality
Patient Interest
Institutional Values
Making Ethical Decisions
Ethical Issues in Implementation Planning
Patient Record Integrity
Security
Additional Ethical Issues in Implementation Planning
Scenario 11-B: Differences When Linking EHR Systems
User Access
Security Practices
Data Quality/Integrity
Confidentiality Agreements
Audit Trails and E-Mail
Conclusion
Key Terms
Chapter Summary
References
Ethical Decision-Making Matrices
-Scenario 11-A: Patient Record Integrity and System Security
-Scenario 11-B: Differences When Linking EHR Systems
Chapter 12	Information Security
Karen Czirr, MS, RHIA, CHP
Karen A. Rosendale, MBA, RHIA
Emily West, RHIA
Learning Objectives
Abstract 
Scenario 12-A: A Curious Human Resource Employee
The Health Care Information Revolution
Concepts In Information Security
Privacy, Confidentiality, Disclosure, Need To Know
Privacy Related Security
Confidentiality, Integrity, Availability
Establishing A Security Baseline
Policies and Procedures
Policies and Procedures
Access Control
Audit Trails
Scenario 12-B: Failure To Log Off of the System
Workstation Use and Security
Internet, Email and E-Health
Conducting a Risk Analysis 
Ways to Identify Vulnerabilities
Scenario 12-C: Storing Data on a Laptop Computer
Managing the Partnerships
Patient Notification and Informed Consent.
The Role Of The Information Security Officer
A Model Outline For An Information Security Program
Chapter Summary
Key Terms 
Ethical Decision-Making Matrices
-Scenario 12-A: A Curious Human Resource Employee
-Scenario 12-B: Failure To Log Off of the System
-Scenario 12-C: Storing Data on a Laptop Computer
Chapter 13	Software Development and Implementation
Susan H. Fenton, MBA, RHIA 
Learning Objectives 
Abstract 
Scenario 13-A: Planning The EHR: Competing Interests
Consultant Approach
Information Gathering 
Physician, Chief of the Medical Staff
Chief Financial Officer (CFO)
Information Technology (IT) Specialist
Health Information Management (HIM) Director
A Collaborative Approach To Decision Making
Conclusion
Key Terms 
Chapter Summary
References 
Ethical Decision-Making Matrix 
	-Scenario 13-A: Planning The EHR: Competing Interests
Chapter 14	Data Resource Management
Frances Wickham Lee, DBA
Andrea W. White, PhD, RHIA
Karen A. Wager, DBA, RHIA
Learning Objectives
Abstract 
Data Resource Management In Health Care
Impact Of HIPAA Regulations On Data Resource Management
Data Resource Management Tools
Database and Data Decision Tools
Electronic Health Records 
Ethical Dilemmas For Data Resource Managers
Scenario 14-A: The Physicians Resist a New Password Policy
Scenario 14-B: Threat to Integrity of the CDR
Scenario 14-C: Research Access to Admission/Discharge/Registration Data
Conclusion
Key Terms 
Chapter Summary
References
Ethical Decision-Making Matrices
-Scenario 14-A: The Physicians Resist a New Password Policy
-Scenario 14-B: Threat to Integrity of the CDR
-Scenario 14-C: Research Access to Admission/Discharge/Registration Data
Chapter 15	Integrated Delivery Systems
Brenda Olson, M.Ed., RHIA, CHP
Karen Gallagher Grant, RHIA, CHP
Learning Objectives
Abstract
Scenario 15-A: Scheduling Clerk Has Access to All Clinical Information
Privacy And Security Issues In The IDS
Data Quality Issues In The IDS
Scenario 15-B: Inconsistencies in the MPI
Skills For HIM Professionals In The IDS
Conclusion
Key Terms
Chapter Summary
References 
Ethical Decision-Making Matrices
-Scenario 15-A: Scheduling Clerk Has Access to All Clinical Information
-Scenario 15-B: Inconsistencies in the MPI
PART IV Summary
Chapter 16	E-Health for Consumers, Patients and Caregivers
Cynthia Baur, PhD
Mary Jo Deering, PhD
Learning Objectives
Abstract 
Scenario 16-A: Equity and Privacy
E-Health And The Changing Health Care System
E-Health And National Policy
E-Health And The Health Information Management Professional
Some E-Health Ethical Issues
Choice and Interoperability
Scenario 16-B: Ensuring On-line Quality and Privacy Protections
Emerging Issues
Conclusion
Key Terms
Chapter Summary
References 
Ethical Decision-Making Matrices
	-Scenario 16-A: Equity and Privacy
	-Scenario 16-B: Ensuring On-line Quality and Privacy Protections
Appendix 16-A: Examples of guidelines, policies, or codes of conduct for health Websites
Chapter 17	E-HIM: Information Technology and Information Exchange
Meryl Bloomrosen, MBA, RHIA 
Learning Objectives 
Abstract 
Introduction
Goals and Objectives
Managing Electronic Health Records and Information
HIM Roles and Responsibilities
Public and Private Sector Activities
Health Information Exchange
Ethical Challenges 
Scenario 17-A: HIM Professionals¿ Role in eHIMTM. No decision-making matrix for this scenario.
Conclusion
Chapter Summary 
Key Terms 
Selected References and Resources (References also footnotes) 
Chapter 18	Genetic Information
Barbara P. Fuller, JD, RHIA
Kathy L. Hudson, PhD
Learning Objectives
Abstract 
Scenario 18-A: Genetic Privacy
The Issue Of Genetic Information
The Relationship Between Genetic Information and Generic Medical Information
What Do We Mean By Privacy Of Medical Information?
Research Records
The Misuse Of Genetic Information And Discrimination
Federal Legislative Protections
State Legislative Protections
Legislation On Research Record Privacy
Ethical Issues For The HIM Professional
Key Terms 
Chapter Summary
References 
Footnotes 
Ethical Decision-Making Matrix
	-Scenario 18-A: Genetic Privacy
Chapter 19	Adoption Information
Martha L. Jones, PhD, LSW
Learning Objectives
Abstract 
Scenario 19-A: Seeking Information Many Years Later
Adoption: Historical And Emerging Ethical Issues
Who¿s Who In Adoption: Some Explanations Of Terminology
Ethical Issues For HIM Professionals
Adoptive Parents Seek Information on Their Adopted Child
Scenario 19-B: An Adoptee Seeks Information on Her Biological Family
Scenario 19-C: A Birth Mother Seeks Information on Her Biological Son
Future Issues
Key Terms 
Chapter Summary
References 
Ethical Decision-Making Matrices 
-Scenario 19-A: Seeking Information Many Years Later
-Scenario 19-B: An Adoptee Seeks Information on Her Biological Family
-Scenario 19-C: A Birth Mother Seeks Information on Her Biological Son
Chapter 20	Drug, Alcohol, Sexual, and Behavioral Information
Sharon J. Randolph, JD, RHIA
Laurie A. Rinehart-Thompson, JD, RHIA, CHP
Learning Objectives
Abstract 
Scenario 20-A: The Arrest Warrant: Is This Person in Your Facility?
Substance Abuse/Treatment, Health Information And The Law
Ethical Challenges In Behavioral Health And Substance Abuse/Treatment 
Law Enforcement Requests Patient-Identifying Information
Law Enforcement Requests Patient Information for Public Safety Reasons
Scenario 20-B: Safety of a Citizen versus Privacy of a Patient
A Behavioral Health Patient Confesses to a Staff Member That He Has Committed a Crime
Scenario 20-C: Patient Confesses to a Psychiatrist
Scenario 20-D: Patient Confesses to the Nurse¿s Aide
	Protecting Information about a Patient¿s Admission to a Behavioral Health 
Unit of a General Hospital
Scenario 20-E: Verifying Admission Can Violate Privacy
Requests for Information on Sexually Transmitted Diseases
Scenario 20-F: A Prisoner with Possible AIDS
Requests about Employees and Children 
Scenario 20-G: Workers¿ Compensation Case
Scenario 20-H: Children¿s Protective Services
Conclusion
Key Terms
Chapter Summary
References 
Ethical Decision-Making Matrices
-Scenario 20-A: The Arrest Warrant: Is This Person in Your Facility?
-Scenario 20-B: Safety of a Citizen versus Privacy of a Patient
-Scenario 20-C: Patient Confesses to a Psychiatrist
-Scenario 20-D: Patient Confesses to the Nurse¿s Aide
-Scenario 20-E: Verifying Admission Can Violate Privacy
-Scenario 20-F: A Prisoner with Possible AIDS
-Scenario 20-G: Workers¿ Compensation Case
-Scenario 20-H: Children¿s Protective Services
PART V Summary 
Chapter 21 	Management
Cathy Flite, M.Ed., RHIA
Sharon Laquer, MS, RHIA
Learning Objectives
Abstract 
Scenario 21-A: Lateness and Absenteeism
Moral Development & Awareness
Table 21-A: Kohlberg¿s Stages of Moral Development
Scenario 21-B: National Convention Misadventures
Socialization of a New Employee
Socialization
Rationalization
Equity
The Code of Ethics is Not Enough
Scenario 21-C: Avoiding the employee who will be fired
When Ethical Leadership Fails
Scenario 21-D: Failure to document poor work performance on a nice guy
Manager muteness when evaluating employees
Conclusion
Chapter Summary
Glossary 
Key Terms
References 
Ethical Decision-Making Matrices
-Scenario 21-A-1 and 2: Lateness and Absenteeism
	-Scenario 21-B: National Convention Misadventures
-Scenario 21-C: Avoiding the employee who will be fired
-Scenario 21-D: Failure to document poor work performance on a nice guy
Chapter 22	Entrepreneur
Marie Gardenier, MBA, RHIA
Learning Objectives
Abstract 
Scenario 22-A: Competing Constituencies
Entrepreneurship In Health Information Management
Defining the Entrepreneur
Entrepreneur versus Intrapreneur
Business Ethics: Concepts And Principles
Contracts
Advertising
The Profit Motive
Corporate Responsibility
The Case for Ethics in Business
The Intersection Of Ethics And HIM Entrepreneurship
Function-Based Issues for the Consultant
Delivering a Difficult Message
Advice Not Taken
Conflicts of Interest
Scapegoating 
Special Opportunities for the Consultant To Act as Moral Voice
Relationship-Based Issues for the Independent Contractor
Scenario 22-B: Negotiating Contracts
Scenario 22-C: Unrealistic Client Expectations
Scenario 22-D: Discovering Sensitive Information about a Client, Competitor or Colleague
Conclusion
Key Terms
Chapter Summary
References
Additional Resources 
Ethical Decision-Making Matrices
-Scenario 22-A: Competing Constituencies
-Scenario 22-B: Negotiating Contracts
-Scenario 22-C: Unrealistic Client Expectations
-Scenario 22-D: Discovering Sensitive Information about a Client, Competitor or Colleague
Chapter 23	Vendors
Keith Olenik, MA, RHIA, CHP
Learning Objectives
Abstract 
Scenario 23-A: Vendor Request
Vendor Relations
Sales Ethics
Scenario 23-B: Vendors as Friends
Scenario 23-C: Gifts
Scenario 23-D: Preferred Vendors
Request for Proposal
Introduction
Directions
Standard text
Statement of work
Social Responsibility
Ethical Considerations for the RFP Process
Scenario 23-E: Negotiating
Enhancement of Vendor Relationships
Future Issues
Key Terms 
Chapter Summary
References 
Ethical Decision-Making Matrices
-Scenario 23-A: Vendor Request
-Scenario 23-B: Vendors as Friends
-Scenario 23-C: Gifts
-Scenario 23-D: Preferred Vendors
-Scenario 23-E: Negotiating
Appendix 23-A: Sample Gifts Policy
Chapter 24	Advocacy
Susan Helbig, MA, RHIA
Learning Objectives 
Abstract 
Scenario 24-A: Violating Privacy of a Prominent Citizen
Advocacy: The choice of ethics in action
Advocating For Patients
	The Patient¿s Bill of Rights
Health Information: Individual Patient and Collective Patients Stories
Scenario 24-B: Compassion in Action for an Alcoholic Peer
Advocating For Peers
Scenario 24-C: Cockroaches in the HIM Department
Advocating For Staff
Scenario 24-D: Unfair Treatment of Part-time Workers
Advocating For The Health Care Organization
Scenario 24-E: Small Print on a Consent Form
Advocating For The Larger Community And Society
Scenario 24-F: The Data Warehouse Wants To Sell Patient Information
Advocating for one¿s self
Conclusion
Key Terms
Chapter Summary
References
Ethical Decision-Making Matrices
	-Scenario 24-A: Violating Privacy of a Prominent Citizen
-Scenario 24-B: Compassion in Action for an Alcoholic Peer
-Scenario 24-C: Cockroaches in the HIM Department
-Scenario 24-D: Unfair Treatment of Part-time Workers
-Scenario 24-E: Small Print on a Consent Form
-Scenario 24-F: The Data Warehouse Wants To Sell Patient Information
Appendix 24-A: Example of Organizational Engagement in Societal Advocacy
Appendix 24-B: Precepts of Effective HIM Advocacy
Appendix 24-C: A Patient¿s Bill of Rights

Library of Congress Subject Headings for this publication:

Health -- Information services -- Management -- Moral and ethical aspects.
Medical care -- Information services -- Moral and ethical aspects.
Information Management -- ethics.
Medical Records -- standards.
Confidentiality -- ethics.
Ethics, Professional.