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32 terms

Medical Transcription Ch1 Vocabulary

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Advanced Directive
A power of attorney that permits someone to make decisions for a patient who is incompetent to do so.
Americans with Disabilities Act
Prohibits private employers, state and local governments, employment agencies, and labor unions from discriminating against qualified individuals with disabilities.
Breach of confidential communication
The unauthorized release of information about a patient.
Confidentiality
Treatment of a patient's medical information as private and not for publication.
Custodian of records
A person put in charge of medical records.
Damages
Compensation to those who have been injured as a result of another's negligance or incompetence.
Documentation
The supplying of written or printed official information that can be used for evidence.
Do-not-resuscitate order (DNR)
Specifics concerning what should and should not be done to revive a patient who has experienced cardiac or pulmonary arrest.
Electronic signature
A process whereby a document is legally signed by computer directive.
Ethics
Moral principles and standards in the ideal relationships between physicians and patients or other physicians.
Etiquette
Customs, rules of conduct, courtesy, and manners of the medical profession.
Fraud
A criminal misrepresentation by an individual for benefit to himself or herself or to another.
Gross negligence
Extreme departure from the standard of care.
healthcare directive
A statement made by a competent individual outlining preferences for medical treatment in the event that he or she is unable to make decisions at the time care is needed.
Independent contractor
A person who is not an employee but is hired to perform a specific job for the employer and is free to perform the work the contractor chooses.
Informed consent
An agreement to permit something to happen after the patient is informed of the risks involved and advised of alternatives for care.
Invasion of right to privacy
Unwarranted exploitation of another's personality or personal affairs with which one has no legitimate concern in such a way to cause mental anguish.
Libel
A false written or graphic statement to a third person that damages the reputation of a patient or subjects a patient to ridicule.
Life-sustaining procedure
A medical procedure in which artificial means are used to sustain life ane postpone death.
Malpractice
Negligence or incompetence in the performance of duties to a client that results in injury or death.
Medical record
Written or computer stored information, tissue samples, log books, or x-ray films.
Medical report
Written or computer stored information about a patient's medical history. The report is part of the medical record.
Negligence
Injury or death due to failure to exercise reasonable care or the care required by the circumstance; failure to do something to prevent death or injury
Protected health information (PHI)
Any part of an individual's identifiable health information that is collected by the healthcare provider and is maintained or transmitted by electronic media
Release of information
Medical information given out to a third party with the written authorization of the patient.
Respondent superior
"Let the master answer" A physician is liable in certain cases for the wrongful acts of his or her assistants or employees.
Risk management
A department to prevent situations that can lead to liability.
Slander
A false spoken statement made in the presence of others that damages a person's reputation or subjects a person to ridicule.
Statutory employee
Basically an independent contractor who is treated as an employee.
Subpoena duces tecum
A subpoena that requires the appearance of a witness with his or her records as a deposition, trial, or other legal proceeding.
Verbatim
Word for word.
Defamation
A commom tort; injury to reputation-that is slander or libel.