Law & Ethics Chapter 9

Created by kristen81783 

Upgrade to
remove ads

Credible

believable or worthy of belief

Credibility Gap

an apparent disparity between what is said or written and the actual facts

Disclosed

made known

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

JCAHO

Microfiche

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

SOAP

Subpoenaed

a medical record ordered by the court to be available during a malpractice case

Medical Record

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

Medical Record

must include patient care information such as admitting diagnosis, physician exam report and documentation of complications and discharge summary and follow up care

Chronological

disadvantage of this documentation system is medical problems may go undiscovered

30

federal reimbursement guidelines require that all medical records be completed within how many days following the patients discharge from a hospital

Incomplete

this type of medical record makes it impossible for the health care provider to defend allegations in court

Wasn't Done

for court purposes, if documentation doesn't appear in the medical record it...

Written Consent

to protect patient confidentiality, medical records can be released only with the patients....

Physician

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...

Medical Records

usually exempt from state open record laws except when the benefit of disclosure for the public interest or safety outweighs confidentiality

10

all medical records should be stored for how many years from the date of the last entry

Older Records

these types of records of former patients can be stored in a clean, dry storage space

Computerized

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

Medical Records

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

Permanently

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...

Patient

physicians who wish to disclose confidential medical record information should discuss it with who first

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set