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13 Cards in this Set
- Front
- Back
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credibility gap
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an apparent disparity between what is said or written and the actual facts
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credible
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believable or worthy of belief
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disclosed
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made known
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doctrine of professional discretion
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mean that a physician may determine, based on his or her best judgment, if a patient with mental or emotional problems should view the medical record
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Electronic medical record EMR
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EMTAKA a section of cobra dealing with patient dumping
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encryptions
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scrambling and encoding information before sending it electronically
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firewalls
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software to prevent unauthorized users
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medical record
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all the written and computer generated documentation relating to a patient
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microfiche
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miniaturized photograph of records
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open-record laws
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state freedom of information laws that grant public access to records maintained by state agencies
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public health services act
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protects patients who are receiving treatment for drug and alcohol abuse
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subpoenaed
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court order for a person or documents to appear in court
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timeliness of documentation
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all entries into a medical record should be made as soon as they occur or as soon as possible afterward
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