Confidentiality, Privacy & Security

1.  Subpoena

Posted 9 days ago
Good morning,
Could someone please help me with this? The Deputy District Attorney wants the custodian to appear in court and answers these following questions:

"I'll ask who creates the records, whether records are created in the ordinary course of business, how they're stored, policies & procedure to preclude tampering, and whether the produced records are true and accurate copies. 

     Do you want to do a dry run & practice? The questions will be straight forward.Thanks for your time and assistance"

My Risk Management and I would like how we should answer these questions? Would the IT supervisor also be subpoenaed?



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Cyli Torres
Medical Records Supervisorjavascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$MainCopy$ctl02$BtnSave", "", true, "", "", false, true))
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2.  RE: Subpoena

Posted 9 days ago
This is a normal proceeding. Nothing to be worried about. I have had to appear in court and answer the same questions many times.
As custodian you will simply answer the question as it is put to you, offering no more information than what is asked. The records are your business records. I would suggest that you review the records before you send them so you know what is in the records that are being presented in court. You really want to make sure that you don't have anyone else records stuck in with them.


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Bonnie Ormond
Director of Medical Records
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3.  RE: Subpoena

Posted 9 days ago
​I was not here on the day these records were printed and sent.  It was my risk management who signed and reviewed the records,can I still go as her representative?

We have never had to appear in court and are looking for guidance on how to properly answer these questions. My risk management advised me to only answer the question of whether the records are true and accurate copy and no to answer any other questions.


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Cyli Torres
Medical Records Supervisor
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4.  RE: Subpoena

Posted 8 days ago
If you go to court and do not answer the lawyers questions when you are on the stand the judge can hold you in contempt of court. Be honest  and say that to the best of your knowledge the records are true and accurate
copies of the medical record and that they were printed and assembled by .........

You don't know who they will ask to testify- usually I am the only one.

Bonnie Ormond, RHIA
Director Health Information Management
Carteret Health Care
3500 Arendell Street, Morehead City, North Carolina 28557
Office: 252-808-6529  I  Cell: 252-269-4555  I bormond@carterthealth.org



On Tue, Nov 14, 2017 at 3:03 PM, Cyli Torres via American Health Information Management Association






5.  RE: Subpoena

Posted 8 days ago
Another option may to ask the district attorney if you could certify the records and answer the questions in the letter of certification.  It might save you a court appearance.  Or you could ask to manage it that way in the future after the initial court appearance.  It sounds like you may have a new DA who is not well versed in this.

I have been certifying records for years without court appearances.   In addition, you might want to qualify your statement with:  "To the best of my knowledge..."

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Nancy Davis, MS, RHIA, CHPS
Director of Compliance & Safety
Door County Medical Center
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6.  RE: Subpoena

Posted 8 days ago
Concur with Bonnie that affidavit / certification IF the DA is amenable is by and far the easiest way to go. IF however DA wants Records Custodian on the stand have this to offer:


Not telling the DA their job but he/she may need a little coaching. What you've shared are the standard questions put forth for admitting records into evidence under the Business Records Exception rule. If he/she phrases the questions in such way that you can provide straight Yes/ No answers then you should be well-equipped to serve as the Records Custodian witness for your organization.  

Rather than asking you "WHO creates…" he/she should ask "Were these records created by individuals with personal knowledge of the acts and events recorded in this record" to which you reply "Yes"

Rather than asking you "HOW are the records stored and protected from tampering" he/she should ask "Are these records stored and handled in such a manner as to preclude tampering" to which you reply "Yes"

Phrasing the questions the way he/she is doing it could/would require testimony from others such as your IT staff unless you are well-versed in the technology in your organization. If opposing counsel is amenable to having the records admitted into evidence your Yes/No testimony is a mere LEGAL formality and you'll be done. However if DA anticipates objection from the other side, then you may want/need to bring IT along. Just don't get drawn into answering questions outside of your scope of knowledge and practice. Eg. being asked "what does the doctor mean by this note?" Answer: "I don't know, you will have to ask the doctor." You can certainly read an entry in a chart but anything beyond that (eg.interpretation of meaning) requires the testimony of the author of the entry. Same goes for technical security practices – answer what you have personal knowledge of, then for anything beyond that it is best to reply, "I don't know, you will need to ask our Director of IT".  Hope this helps. All the best…



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Kealia Folck
University of Kansas HIM Faculty
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