an apparent disparity between what is said or written and the actual facts.
believable or worthy of belief.
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.
scrambling and encoding information before sending it electronically.
software to prevent unauthorized users.
all written and computer-generated documentation relating to the patient.
miniaturized photographs of records.
state freedom-of-information laws that grant public access to records maintained by state agencies.
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.
ordered by the court.
Timeliness of documentation
all entries should be made as soon as they occur or as soon as possible afterward.