Ch. 9 The Medical Record Flashcards
1
Q
Credibility gap
A
- An apparent disparity between what is said or written and the actual facts
2
Q
Credible
A
- Believable or worthy of belief
3
Q
Disclosed
A
- Made known
4
Q
Doctrine of professional discretion
A
- A physician may determine, based on his or her best judgment, if a patient with mental or emotional problems should view the medical record
5
Q
Electronic health record (EHR)
A
- Electronically captured health information that includes tracking clinical conditions, reporting clinical quality measures, and using this information to include patients and their families in their care
6
Q
Electronic medical record (EMR)
A
- Fully computerized method of record-keeping
7
Q
Encryptions
A
- Scrambling and encoding information before sending it electronically
8
Q
Firewalls
A
- Software to prevent unauthorized users
9
Q
Health record
A
- All written and computer-generated documentation relating to the patient
10
Q
The Joint Commission
A
- An agency that oversees hospital accreditation standards, or Medicare requirements as the minimum standard
11
Q
Medical record
A
All the written and computer generated documentation relating to a patient
12
Q
Microfiche
A
- Miniaturized photographs of records
13
Q
Open-record laws
A
- State Freedom of information laws that grant public access to records maintained by state agencies
14
Q
Personal health record (PHR)
A
- A record of information, often in the patient’s own words, that is controlled by the patient or patient’s family
15
Q
Privileged communication
A
- Confidential information that has been told to a physician (or attorney) by the patient
