hosa chapter 9

Timeliness of documentation

all entries should be made as they occur or as soon as possible afterward.

credible

t must be believable or worthy of belief, trustworthy, and reliable

credibility gap

exists if there is an apparent disparity between what is said or written and the actual facts

privileged communi cation

(confidential information told to their physician

doctrine of professional discretion

a physician may determine, based on his or her best judg ment, if the patient with mental or emotional problems should view the medical record

open-record laws

grant pub lic access to records maintained by state agencie

disclosed,

made known

Public Health Services Act

protects patients who are receiving treatment for drug and alcohol abuse.

EMR

electronic medical record. Data and patient records can be created, modified, authenticated, stored, and retrieved by the computer. This has made record maintenance and retrieval much more efficient and effective in medical offices, clinics, laboratories, and hospitals. However, it has resulted in increased concerns about patient privacy as so many healthcare professionals may now be able to view a patient record unless precautions are taken.

encryptions

scrambling and encoding information before sending it electronically

firewalls

software to prevent unauthorized users