believable or worthy of belief
an apparent disparity between what is said or written and the actual facts
Doctrine of Professional Discretion
means a physician may determine, based on his best judgment, if a patient with mental or emotional problems should view the medical record
Joint Commission on Accreditation of Healthcare Organizations
miniaturized photographs of records
Open Record Laws
state freedom on information laws that grant public access to records maintained by state agencies
Problem Oriented Medical Record
method of documentation that focuses on the patients problems not just on the diagnosis
Subjective, Objective, Assessment, Plan of Action
a medical record ordered by the court to be available during a malpractice case
purpose is to provide the medical picture and record of the patient from birth to death and to provide data and statistics on health matters
must include patient care information such as admitting diagnosis, physician exam report and documentation of complications and discharge summary and follow up care
disadvantage of this documentation system is medical problems may go undiscovered
federal reimbursement guidelines require that all medical records be completed within how many days following the patients discharge from a hospital
this type of medical record makes it impossible for the health care provider to defend allegations in court
for court purposes, if documentation doesn't appear in the medical record it...
to protect patient confidentiality, medical records can be released only with the patients....
ownership of the medical record usually remains with the...
Veterans Administration Hospitals
privacy act of 1974 protects private citizens from distribution of information about themselves by the federal government except...
usually exempt from state open record laws except when the benefit of disclosure for the public interest or safety outweighs confidentiality
all medical records should be stored for how many years from the date of the last entry
these types of records of former patients can be stored in a clean, dry storage space
this type of medical records pose problems of confidentiality, make record maintenance and retrieval more efficient and should be accessed on a need to know basis
laws regarding these may vary from state to state
Civil and Criminal
health care providers and institutions who disclose confidential health information may face these types of liability for disclosure
immunization records should be kept...
Subpoena Duces Tecum
written order requiring a person to appear in court, give testimony and bring records described is called...
physicians who wish to disclose confidential medical record information should discuss it with who first