a legal document prepared by a living, competent adult to provide guidance to the health care team if the individual should become unable to make decisions regarding his or her medical care; may also be called a living will or durable power of attorney for health care
Authorization to disclose information
This document allows the healthcare facilty to verbally disclose or send health informaiton to other organizations (other than those provided as part of HIPAA).
Consent for treatment
Hospitals that are accredited by approved accreditation organizations (e.g., JCAHO) are determined to have met or exceeded Conditions of Participation to participate in the Medicare and Medicaid programs.
permission that must be obtained from every responsive, competent adult patient before medical care may be rendered
A health record that uses components of both paper and electronic systems.
type of consent in which a patient who is unable to give consent is given treatment under the legal assumption that he or she would want treatment
A mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors
Medical staff privileges
care for terminally ill patients consisting of comfort measures and symptom control.
Patient's Bill of Rights
A statement approved by the American Hospital Association in 1973, guaranteeing an individual's rights to certain courtesies and considerations while a hospital patient, published by the american hospital association. patients rights to participate in their health care as well as provider responsibilities, emphasizes patient autonomy and defines the the limits of provider influence and control
The Health Record contains what 2 types of data?
administrative data and clinical data
AHIMA e-HIM Workgroup definition:
A hybrid health records is a system with functional components that:
- include both paper and electronic documents
- use both manual and electronic processes