Chapter 9
Order by
14 terms
Terms | Definitions |
|---|---|
 Credibility gap | an apparent disparity between what is said or written and the actual facts. |
| Credible | believable or worthy of belief. |
| Disclosed | made known |
| Doctrine of professional discretion | a physician may determine, based on his or her best judgment, if a patient with mental or emotional problems should view the medical record. |
| Electronic medical record (EMR) | fully computerized method of record keeping. |
| Encryptions | scrambling and encoding information before sending it electronically. |
| Firewalls | software to prevent unauthorized users. |
| Medical record | all written and computer-generated documentation relating to the patient. |
| Microfiche | miniaturized photographs of records. |
| Open-record laws | state freedom-of-information laws that grant public access to records maintained by state agencies. |
| Privileged communication | confidential information that has been told to a physician (or attorney) by the patient. |
| Public Health Services Act | protects patients who are receiving treatment for drug and alcohol abuse. |
| Subpoenaed | ordered by the court. |
| Timeliness of documentation | all entries should be made as soon as they occur or as soon as possible afterward. |
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