Question | Answer |
Entity | is an existing or real thing |
HIPPA | Federal Law protectig privacy and other patient heatlh care rights |
Subpoena duces tecum | Legal document requiring the recipient to bring certain written records to court to be used as evidence in a lawsuit |
Electronic transmissions | sending of information from one network-connected computer to another |
PHI | Protected Heatlh Information; Information that contains one or more patient identifiers |
AMA | American Medical Association |
Medical Record | a collection of data recorded when a patient seeks medical treatment |
POMR | Problem Oriented Medical Record |
SOAP | Subjective information, Objective Information, Assessment (MD evaluation-or other licensed assessor), Plan |
"the five C's of doctumentation" | Concise, Complete and objective, Clear and legibly written,Correct, Chronologically ordered |
Consent | Permission from a patient, either expressed or implied, for something to be done by another |
Informed Consent | The patients right to recieve all information relative to his or her condition and then to make a decision regarding treatment based upon that knowledge |
Mentally Incompetent | Unable to fully understand all the terms and conditions of a transaction, and therefore unable to enter into a legal contract |
Minor | Anyone under the age of majority, 18 or 21 |
Invasion of privacy | Intrusion into a person's seclusion or into his or her private affairs |
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 |
De-identify | To remove all information that identifies patients from health care transactions |