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MED149 Chapter 7
| Term | Definition |
|---|---|
| Privacy | Individuals right to control who can gain access to information |
| Confidentiality | describes a situation where information is provided with exception that it will not be disclosed to others or beyond what is agreed. |
| Medical record | a collection of data recorded when a patient seeks medical treatment |
| Addendum | a significant change or addition to the electronic health record (EHR) |
| Doctrine of professional discretion | a principle under which a physician can exercise judgment as to whether to show patients who are being treated for mental or emotional conditions their records |
| Fiduciary duty | a physician's obligation to his or her patient, based on trust and confidence |
| Confidentiality of Alcohol and Drug Abuse, Patient Records | a federal statute that protects patients with histories of substance abuse regarding the release of information about treatment |
| Consent | permission from a person, either expressed or implied, for something to be done by another |
| Doctrine of Informed Consent | the legal basis for informed consent, usually outlined in a state's medical practice acts |
| Good Samaritan acts | state laws protecting physicians and sometimes other health care practitioners and laypersons from charges of negligence or abandonment if they stop to help the victim of an accident or other emergency |
| Health information technology (HIT) | the application of information processing, involving both computer hardware and software, that deals with the storage, retrieval, sharing, and use of health care information data, and knowledge for communication and decision making |
| The five Cs for correctly entering information into a medical record | concise, complete, clear, correct, chronologically ordered |
| Electronic Record | digital version of information that is created, stored, and used within computer systems, rather than on physical paper |
| Electronic Health Record | digital version of a patient’s comprehensive medical history, designed to be shared across healthcare providers to improve care coordination and decision-making |
| Vital Statistics | important events in person's life (ex: birth and death dates) used by government and public health agencies to determine population trends and needs. It is a public duty of physicians to collect this data |
| Mortality Rate | death rate (deaths/total population) |
| "First right" individual | individual who has the power of consent for autopsy of the deceased body, unless suspicious cause of death |
| Probable Cause | reasonable belief is needed to investigate |
| "Residential Abuse" | protection of elders being abused by healthcare workers in nursing homes. |
| Food and Drug Administration (FDA) | enforces sale and distribution of Drugs |
| Drug Enforcement Administration (DEA) | enforces regulation of drugs with potential for addiction, habituation or abuse using the Controlled Substances Act of 1970. |
| Beneficence | ethical principle of acting in ways that promote the well-being of others and actively doing good |
| Duty of Care | legal obligation that is imposed on an individual, requiring adherence to a standard of reasonable care to avoid careless acts that could foreseeably harm others |
| Standard of Care | level of caution, skill, and diligence that a reasonably prudent person or professional is expected to exercise in a given situation |
| Advocate | a person who publicly supports or recommends a particular cause or policy |
Created by:
Annalise Schafhauser