Chapter 6 Definitions Flashcards
standards of practice
widely accepted principles intended to guide the professional activities of a health care practioner
medical record
cumulative documentation of a person’s medical history and health-care interventions
problem-oriented medical record (POMR)
a system of medical record keeping that organizes information around a patient’s specific complaints
SOAP note
medical appraisal organized by subjective and objective evaluaiton, assessment of the patient’s problem, and development of a plan for treatment
focus chart
a medical record that registers a patient’s complaint data, the health care practitioner’s actiosn, and the patient’s response
charting by exception
a type of medical record that notes only those patient resposnes that vary form predefined norms
narrative charting
a method of recording the details of a patient’s assessments and treatmetns usign a detailed, prosebased format
dictation
the act of orally recording, on a cassette tape or directly into a computer, the details of a helath care assessment or treatmetn for later transcription and fillig
exculpatory clause
a signed release from a patient or parents that waivers all future legal claims against an athletic trainer or the employing institution
FERPA
(family educational rights and privacy act) sometimes referred to as the Buckley Amendment. a 1974 federal law requiring student authorization to release educational records to a third party and ensuring access for students to their records
HIPPA
the health insurance portability and accountability act of 1996 that helps employees transfew their health insurance when they switch employers, ensures that their health information will remain private, and gives people more access to their own health care information
program administration records
documentation of the activities of a program
requests for proposals (RFPs)
notices from internal and external funding sources announcing the details of grant programs
nonmedical correspondence
letters and memoranda not assocaiated with a specific patient’s health status
OSHA Bloodborne pathogen standards
federal government rules that require employers to protect employees against the accidental transmission of bloodborne pathogens, especially HIV and hepatitis B
