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CHAPTER 7

QuestionAnswer
MEDICAL RECORD a collection of data recorded when a patient seeks medical treatment.
ELECTRONIC MEDICAL RECORD (EMR) A digital version of the paper charts in the clinician's office. An EMR contains the medical treatment history of patients.
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 info 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.
Electronic health record (EHR) An electronic collection of medical records from a variety of providers.
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: rosamundo
 

 



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