Chapter 6: Information Management Flashcards
Standards of Practice
widely accepted principles intended to guide the professional activities of a health care practitioner
Medical Record
cumulative documentation of a person’s medical history and healthcare interventions
Problem-Oriented Medical Record (POMR)
system of medical record keeping that organizes information around a patient’s specific complaints
SOAP Note
medical appraisal organized by subjective and objective evaluation, assessment of the patient’s problem, and development of a plan for treatment
Focus Charting
medical record that registers a patient’s complaint data, the health care practitioner’s actions, and the patient’s response
Charting by Exception
type of medical record that notes only those patient responses that vary from predefined norms
Narrative Charting
method of recording the details of a patient’s assessments and treatments using a detailed, prose-based format
Dictation
act of orally recording, on a cassette tape or directly into a computer, the details of a health care assessment or treatment for later transcription and filing
Exculpatory Clause
signed release from a patient or parents that waives all future legal claims against an athletic trainer or the employing institution
Family Educational Rights and Privacy Act (FERPA)
Buckley Amendment; 1974 law requiring student authorization to release educational records to a third party and ensuring access for students to their records
Health Insurance Portability and Accountability Act (HIPPA)
from 1996, that helps employees transfer their health insurance when they switch employers, ensures 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
Non-medical Correspondence
letters and memoranda not associated with a specific patient’s health status
OSHA Bloodborne Pathogen Standard
federal government rules that require employers to protect employees against accidental transmission of bloodborne pathogens
