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Medical Ethics CH 7
| Question | Answer |
|---|---|
| addendum | A significant change or addition to the electronic health record (EHR). |
| 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. |
| telemedicine | The remote delivery of health care services and clinical information using telecommunications technology. |
| patient portal | A secure online site that gives patients 24-hour availability to their health records. |
| The Five Cs of Medical Records | Healthcare entries must always be: Concise Complete (and objective) Clear Correct Chronologically ordered |
| Correction | Fixing an inaccuracy. In paper records, done by drawing a single line through the error, writing the correction, signing/initialing, dating, and timing it. |
| Addendum | Adding new, additional information to an existing original electronic entry. |
| Amendment | Clarifying or correcting information specifically within an electronic health record. |
| MBI (Medicare Beneficiary Identifier) | The updated insurance card identifier that replaced Social Security Numbers to fight identity theft |
| Invasion of Privacy | A legal charge that can occur if a patient's image (photographs/videos) is recorded or published without explicit, proper written consent |
| Physical Ownership | The physical or electronic record belongs to the healthcare provider or facility that created it (considered part of their business records) |
| Information Ownership | The patient "owns" and has control over the actual data/information contained within the record |
| Doctrine of Professional Discretion | A legal principle stating that a healthcare provider may withhold records from patients treated for mental or emotional conditions if viewing them could cause the patient harm |
| Job-Related Physicals | Records from employer-paid exams belong to the facility that created them; employers are only entitled to the specific portion relevant to the job requirements |
| Statute of Limitations | The legally defined period (typically 2 to 7 years for adults) that a record must be kept before it can be destroyed |
| Age of Majority | For minors, records must generally be kept until they reach adulthood (18 to 21, depending on the state) plus the standard statute of limitations period |
| False Claims Act | Federal law allowing claims to be brought up to 7 to 10 years after an incident, making longer record retention a prudent practice |
| Written Permission | The mandatory signed consent required from a patient or legal representative before medical records can be released to a third party |
| Scope of Release | The principle that only the specific information requested (e.g., specific dates, diagnoses, or symptoms) should be sent, rather than unsolicited records or the entire file |
| Insurance Claims | Information supplied to insurers to process claims. Authorization is typically built directly into the patient registration form to streamline care |
| Transfer to Another Physician | Photocopying or summarizing records to send to a new provider. Under the privacy rule, patient authorization is waived for treatment purposes, provided reasonable safeguards are used |
| Subpoena Duces Tecum | A legal command for a witness to appear in court and bring specific medical records. When this is issued, the patient's written consent is waived |
| Breach of Confidentiality | A legal charge occurring when confidential medical information is released without proper authorization |
| Subpoena Compliance Guidelines (for the Record Custodian) | Verify the attorney's information.Confirm the patient and physician named match records.Verify date and time.Notify the physician and their insurance/legal counsel.Ensure records are complete,but never alter them.Document the page count and itemize the co |
| Right to Rescind | The patient's right to cancel or withdraw their consent to release information at any time, halting any further disclosure |
| Statutory Protections | Specific state and federal laws that require explicit, heightened written consent for highly sensitive health data |
| Statutory Protections specifically | Mental or emotional health treatment HIV testing status Substance use and alcohol abuse treatment records |
| Health Information Technology | The electronic systems healthcare professionals and patients use to store, share, and analyze health information |
| MACRA (Medicare Access and CHIP Reauthorization Act of 2015) | Legislation changing how Medicare rewards clinicians, prioritizing value and patient outcomes over the volume of services provided |
| 21st Century Cures Act (2016) | Law designed to accelerate medical product development. |
| Regulatory Compliance | The legal requirement that AI tools processing insurance claims must strictly comply with HIPAA |
Created by:
LidiaA28