A significant change or addition to the electronic health record (EHR).

Confidentiality of Alcohol and Drug Abuse Patient Records

A federal statute that protects patients with histories of “substance use problems” or “substance use disorder” regarding the release of information about treatment

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. Disclosure depends on whether, in the physician’s judgment, such patients would be harmed by v

electronic health record (EHR)

An electronic collection of medical records from a variety of providers.

electronic medical record (EMR)

A digital version of the patient’s chart in a clinician’s office.

health information technology (HIT)

The electronic systems health care professionals and increasingly, patients use to store , share, and analyze health information

A process by which health care providers use an electronic health record according to guidelines set by the federal government.

A collection of data recorded when a patient seeks medical treatment.

A secure online site that gives patients 24-hour availability to their health records.

Forms of electronic communication through which users create online communities to share information, ideas, personal messages, and other content in the online environment.

The remote delivery of health care services and clinical information using telecommunications technology.

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chap 7

med 149 Medical Records and Health Information Technology

Term	Definition
addendum	A significant change or addition to the electronic health record (EHR).
Confidentiality of Alcohol and Drug Abuse Patient Records	A federal statute that protects patients with histories of “substance use problems” or “substance use disorder” regarding the release of information about treatment
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. Disclosure depends on whether, in the physician’s judgment, such patients would be harmed by v
electronic health record (EHR)	An electronic collection of medical records from a variety of providers.
electronic medical record (EMR)	A digital version of the patient’s chart in a clinician’s office.
health information technology (HIT)	The electronic systems health care professionals and increasingly, patients use to store , share, and analyze health information
meaningful use	A process by which health care providers use an electronic health record according to guidelines set by the federal government.
medical record	A collection of data recorded when a patient seeks medical treatment.
patient portal	A secure online site that gives patients 24-hour availability to their health records.
Social media	Forms of electronic communication through which users create online communities to share information, ideas, personal messages, and other content in the online environment.
telemedicine	The remote delivery of health care services and clinical information using telecommunications technology.

Created by: AsiBac

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