Chapter 7 Medical Records and Informed Consent

Question 1

5 Cs of documentation

Answer 1

• concise
• complete
• clear and legibly written
• correct
• chronologically ordered

Question 2

medical record

Answer 2

A collection of data record when a patient seeks medical treatment

Question 3

Purpose of medical records

Answer 3

• required by licensing authorities
• provide documentation of patients care
• provide a foundation for managing a pts health care
• legal document
• clinical data for education, research and statistical tracking

Question 4

Correction in a medical chart

Answer 4

draw a line through the error so that it may still be read, initial, date and time. In some cases you must get a witness.

Question 5

doctrine of professional discretion

Answer 5

a principle under which a physician can exercise judgement as to whether to show patients who are being treated for mental or emotional conditions their records. Disclosure depends on whether, in the physicians judgment such patients would be harmed by viewing the records.

Question 6

Routine release of information

Answer 6

• Insurance claims
• transfer to another physician
• use in a court of law

Question 7

fiduciary duty

Answer 7

a physician obligation to his or her patient, based on trust and confidence.

Question 8

Guidelines for releasing information due to a subpoena

Answer 8

• check name on subpoena
• verify carbon copy is the same as original
• verify trial date and time
• notify physician of subpoena
• make sure all records are complete
• document number of pages you photocopied
• offer sworn testimony regarding the record.

Question 9

confidentiality of alcohol and drug abuse patient records

Answer 9

a federal statute that protects patients with histories of substance abuse regarding the release of information about treatment

Question 10

Consent

Answer 10

permission from a person, either expressed or implied, for something to be done by another

Question 11

doctrine of informed consent

Answer 11

the legal basis for informed consent, usually outlined in a states medical practice acts.

Question 12

People who cannot give Informed consent

Answer 12

• minors
• mentally incompetent
• speak limited or no english

Question 13

Good Samaritan Acts

Answer 13

state law protecting physicians and sometimes other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help the victim of an accident or other emergency

Question 14

Health information technology

Answer 14

the application of information processing, involving both computer hardware and software, that deals with the storage,retrieval sharing and use of health care information, data and knowledge for communication and decision making.