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Chapter 12 Keywords

Access The ability to learn the contents of a record by obtaining it or having the contents revealed.
Advance Directive A written document, such as a living will, that specifies a patient’s wishes for his or her care and dictates power of attorney, for the purpose of providing clear instructions in the event the patient is unable to do so.
Amendment A change to the original document
Certification The custodian’s authentication that the copies of the medical records used in litigation are true and complete.
Competency The ability to successfully complete a task or skill
Confidential Communications The sharing of patient health information protected from disclosure in courts, such as patient/physician. Refers to transmission of information to minimize the risk of inadvertent disclosure, such as patient requesting mailing to an alternative address.
Consent An agreement or permission to receive health care services.
Court Order The direction of a judge who has made a decision that an order to produce information (on the record) is necessary.
Custodian The person entrusted with the responsibility for the confidentiality, privacy, and security of medical records.
Discovery The process of investigating the circumstances surrounding a law
Federal Drug and Alcohol Abuse Regulations Regulations at the national level addressing requirements for disclosure of chemical and alcohol abuse patient information.
Hearsay Rule The court rule that prohibits most testimony regarding events by parties who were not directly involved in the event.
Jurisdiction The authority of a court to decide certain cases. May be used on geography, money, or type of case.
Litigation The term used to indicate that a matter must be settled by the court and the process of engaging in legal proceedings.
Negligence Carelessness or lack of foresight that leads to harm or damage
Plaintiff The party who initiated litigation
Preemption The legal principle supporting the HIPAA stipulation that when the privacy regulations conflict with state law, the regulation or law that gives the patient more rights or is more restrictive should prevail.
Release of Information (ROI) The term used to describe the health information department function that provides disclosure of patient health information.
Retention The procedures governing the storage of records, including duration, location, security and access.
Security The administrative, physical, and technologic safeguards used to protect patient health information.
Statue A law that has been passed by the legislative branch of government
Subpoena A direction from an officer of the court.
Subpoena Duces Tecum A direction from an officer of the court to provide documents.
Tort Harm, damage, or wrongdoing that entitles the injured party to compensation.
Verification Confirming accuracy.
Created by: And4987