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believable or worthy of belief

Credibility Gap

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


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



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

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


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

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....


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


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


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


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

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