Term | Definition |
Advance Directive | Document stating an individuals preference of treatment in the event that he/she becomes incompetent or unable to communicate with medical personnel |
Bioethics | Branch of ethics concerning moral issues, questions, and problems that arise in the practice of medicine and in Biomedical research |
Deposition | Preserve the testimony of a witness who is likely to become unavailable for trial |
Ethics | Standards of conduct generally accepted as a moral guide for behavior |
Tort | Wrongful act or injury to a person |
Health Insurance Portability and Accountability Act (HIPAA)
(Intended to...) | (1) Limit health administration cost
(2) Provide for patient information and privacy
(3) Prevent against fraud and abuse |
Living Will | Document stating the desire of a person should he/she become incompetent because of injury or illness and death is imminent |
Plaintiff | One who institutes a lawsuit of action |
Litigation | Lawsuit |
Etiquette | Customary code of conduct, courtesy, and manners |
Consent form | One-time signed document used to disclose personally identifiable health information for treatment, payment, or routine health care operations; NOT required by law |
Defendant | Person being sued (either defending or denying action) |
Malpractice | Carelessness or negligence of a professional person |
Subpoena | a write that commands a witness to appear at a trial |
Complaint | First pleading (court document) of one who initiates action in a civil case |
Authorization form | Document for use and disclosure of Protected Health Information (PHI) NOT in a consent form that describes the purpose for which the health care information is to be used and disclosed |
Civil Law | Statue that enforces private rights and liabilities, as differentiated from criminal law |
Expert Testimony | Statement given concerning a scientific, technical, or professional matter by a person with authority regarding the matter |
Implied consent (contract) | Agreement derived because of implication or the situation, general language, or conduct of the patient |
Protected Health Information (PHI) | Information about the patient's past, present, or future health condition that contains personal identifying data |
Grievance Committee | Impartial panel established to listen to and investigate patients' complaints about medical care or excessive fees |
Privileged communication | Interaction between two parties in which the law recognizes a private, protected relationship. Whatever is communicated between these pairs of parties shall remain confidential, and the law cannot force disclosure of these communications |
Criminal law | Laws (felonies and misdemeanors) made to protect the public against the harmful acts of others. |
Subpoena “Deuces Tecum" | Commands the original medical record in court |
Respondeat superior | Let the master answer |
Portability | The transferbility of an insurance benefit from one source (e.g., job) to another when the worker loses or changes jobs |
Health care power of attorney | Document that names another individual as a decision maker for the patient when the patient is terminally ill or comatose |
Covered entities | Those who provide health care and/or send data electronically, such as; health care professionals, health plans, health care clearinghouses, and hospitals. |
Scope of practice | The range of education, training, ability, and skills a health care professional is expected to have and operate within according to the law and within the standard of care |
Emancipated minors | Children of any age who fall outside the jurisdiction and custody of their parents or guardians and who may make financial and medical decisions |
Risk management | Identifying problem practices or behaviors, then acting to control or eliminate them |
Felony | a crime, typically one involving violence, and usually punishable by imprisonment for more than one year |
Administrative law | Law that governs the activities of government agencies such as the Internal Revenue Service, Medicare, and Medicaid |
Bonding- | Obligation of an insurance company or bonding agency to protect an employer against financial loss caused by the acts or omissions of employees |
Compliance plan- | Written rules outlining practice standards that include federal and state orders |
Libel- | A published false statement that is damaging to a person's reputation; a written defamation |
Contract law- | Agreements that are legally enforceable by law between two or more parties; requires an offer, acceptance of the offer, and promise to perform |
Minimum necessary standard- | Limit the disclosure of PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request |
Arbitration- | An arrangement in which the patient waives the right to sue the physician and, instead, agrees to submit any dispute to arbitration. Arbitration agreements are legal and binding |
Supremacy clause | Declares the constitution, laws, and treaties of the federal government to be the supreme law of the land to which judges in every state are bound regardless of state law to the contrary |
Misdemeanor | An offense that is considered less serious than a felony and carries a lesser penalty, usually a fine or imprisonment for less than 1 year |
Federal law | A body of law at the highest or national level of a federal government. |
Slander | The action or crime of making a false spoken statement damaging to a person's reputation |
Law | The system of rules that a particular country or community recognizes as regulating the actions of its members and may enforce by the imposition of penalties |
HX | History |
T | Temperature |
F | Fahrenheit |
A | Allergies |
lt | Left |
PND | Post Nasal Drip |
Rec | Recommended |
mg | Milligrams |
p.o. | per oral (by mouth) |
q. | daily |
h. | hours |
diag | diagnosis |
URI | Upper Respiratory Infection |
Etiol. | Etiology; the cause of infection |
CXR | Chest X-ray |
CBC | Complete Blood Count |
UA | Urinalysis |
retn | Return/ Retention |
Wks | Weeks |
Oath of Hippocrates | First standards of medical conduct and ethics |
medical ethics | Moral principles and standards in the medical profession |
Bioethics | Branch of ethics concerning moral issues, questions, and problems that arise in the practice of medicine and in biomedical research |
Privileged information | information in a medical record |
Medical Etiquette | Code of conduct, courtesy, and manners customary in the medical profession |
Principles of Medical Ethics | modern code of ethics |
HIPAA stands for | Health Insurance Portability and Accountability Act |
Information about patients past, present, or future health condition that contains personal identifying data is called: | Protected Health Information (PHI) |
The three items a VOLUNTARY signed consent form covers | (1) Treatment
(2) Payments (to doctor)
(3) Health care opperations |
What form must be obtained for use and disclosure of protected health information | Authorization form (form for disclosure) |
Define Compliance Plan | Written document that includes office policies, procedures, and practice standards that are monitored |
Common term for Litigation | Lawsuit |
Another phrase used for Medical Malpractice | Medical Professional Liability |
A physician is legally responsible for any act you preform while in his or her employ. The legal phrase used to describe this responsibility is called: (-----) and means (-----) | Respondeat Superior; Let the master answer |
Three circumstances in which a minor may become emancipated | (1) Minor who is pregnant
(2) Minor in the army
(3) Minor away to school |
Malfeasance | wrongful treatment of the patient |
Misfeasance | lawful treatment done in the wrong way |
Nonfeasance | failure of the physician to do anything |
Malpractice | carelessness of negligence by a professional person |
Criminal negligence | Reckless disregard for the safety of another; being indifferent to an injury that could occur |
Three principal defenses in a malpractice lawsuit | (1) Contributory Negligence
(2) Assumption of risk
(3) Statue of limitations |
Three alternatives to the litigation process | (1) Screening panel (Grievance Committee)
(2) Arbitration (Handled outside of court)
(3) No fault (Malpractice insurance) |
Res Ipsa Loquitor | The thing speaks for itself |
Respondeat Superior | Let the master answer |
Deuce tecum subpoena | Commands the original medical record in court |
Subpoena | Write that commands a witness to appear at a trial |
Deposition | Testimony of a witness under oath and written down before a trial |
Res judicata | already decided by a judge |
Qui facit per alium facit per se | He who acts through another, acts for himself |
Res gestae | Things done, deed |
No compos mentis | Not of sound mind |
4 D's | Duty, Derelict, Direct cause, Damages |
OSHA | Occupational Safety and Health Administration |
CLIA | Clinical Laboratory Improvement Amendment |
FDA (Food and Drug Administration) | protect the health by ensuring safe pharmaceutical products |
DEA (Drug Enforcement Agency) | regulates the distribution of narcotics |
Fraud | intentional perversion of truth |
Medical Directive | allows patient to specify their wishes in regard to four specific dire medical situations by questionaire |
Healthcare proxy | someone to carry out your wishes should you be unable to |
Living will | how you want to live or not live |