Medical Records and Documentation in Imaging Technology

Medical Records

Documents detailing patient's medical history and treatments.

Patient Demographics

Information including name, sex, birth date, and contact.

Medical History

Records of complaints, illnesses, and treatments received.

Laboratory Reports

Results from lab tests conducted during patient care.

Radiology Reports

Findings from imaging studies like X-rays and MRIs.

Problem List

Summary of patient's health issues requiring attention.

Clinical Notes

Progress and consultation notes documenting patient care.

Treatment Notes

Records of medications and procedures administered.

Imaging Procedures

Details of imaging types, dates, and findings.

Reasons for Medical Records

Facilitate communication and protect against errors.

Role of Imaging Technologists

Document imaging procedures and patient reactions.

Procedure Details

Type of imaging and equipment settings used.

Patient Reactions

Responses to procedures, including discomfort or anxiety.

Technical Considerations

Challenges faced during imaging procedures documented.

Continuity of Care

Ensures consistent patient treatment across healthcare providers.

Legal Safeguard

Documentation serves as evidence of care provided.

Comprehensive Documentation

Includes personal info, medical history, and clinical diagnoses.

Treatment Plans

Information on treatments and follow-up imaging studies.

Confidentiality

Protection of patient information from unauthorized access.

Documentation of Procedure

Recording specifics of medical procedures performed.

Active Problem Status

Indicates ongoing health issues in patient's record.

Allergies

Documented sensitivities to substances affecting treatment.

Social History

Patient's lifestyle factors impacting health outcomes.

Medical Record

Legal document detailing patient treatment and care.

Documentation

Records must include time, date, and signatures.

Radiographic Imaging

Specific imaging procedures requiring detailed documentation.

Departmental Protocol

Guidelines for conducting imaging procedures.

Patient Preparation

Instructions provided to patients before procedures.

Medications Administered

List of drugs given to the patient.

Adverse Reactions

Negative responses to medications or treatments.

Treatments Received

Documented care provided to the patient.

Approved Abbreviations

Shortened terms sanctioned by the institution.

Medical Record Format

Structure of records approved by healthcare institutions.

Accrediting Bodies

Organizations that review medical record contents.

Charting Guidelines

Rules to avoid errors in medical records.

NA or 0

Used to fill in blanks on forms.

Year Format

All four digits of the year must be used.

Entry Deletion

Cross out incorrect entries without erasing.

Initial Corrections

Corrections must be initialed and dated.

Confidentiality

Patient information must be kept private.

6 C's of Charting

Principles for effective medical documentation.

Ethical Responsibility

Duty to ensure accurate and timely documentation.

Legibility

Clarity of writing to avoid misinterpretation.

Continuity of Care

Ensures coordinated treatment among healthcare providers.

Electronic Health Records (EHRs)

Digital records for rapid information sharing.

Cultural Sensitivity

Respect for diverse backgrounds in patient care.

HIPAA

Health Insurance Portability and Accountability Act of 1996.

Patient Health Information

Data regarding a patient's health status and treatment.

Authorized Individuals

Persons permitted to access patient information.

Electronic Transactions

Digital processes for healthcare data exchange.

Bill of Rights

Patient's rights regarding privacy and confidentiality.

Cybercrime Prevention Act of 2012

Philippine law addressing cybercrime and data protection.

Republic Act 10173

Philippine Data Privacy Act of 2012.

Health Information Exchange

Sharing of health information across organizations.

Public Exposure

Disclosure of patient information to the public.

Physical Examination Order

Court-ordered medical examination for legal cases.

Public Health and Safety

Protection of community health interests.

Patient Waiver

Patient's written consent to disclose information.

De-identification

Removing personal identifiers from patient data.

Legitimate Access

Authorized access to patient records by providers.

Continued Medical Treatment

Ongoing care requiring sharing of patient information.

Medical Science Advancement

Research and development benefiting from patient data.

Privacy Guidelines

Standards for maintaining patient confidentiality in healthcare.

Health Care Provider

Professional delivering medical services to patients.

Third Party Disclosure

Sharing patient information with unauthorized individuals.

Competent Court Order

Legal directive for disclosure of patient information.

Patient Care Records

Documentation of all patient interactions and treatments.

Cybercrime Prevention Act of 2012

Legislation regulating cybercrime in the Philippines.

Patient Confidentiality

Protection of patient information from unauthorized disclosure.

Sensitive Personal Information

Data requiring special protection due to privacy concerns.

Informed Consent

Patient's agreement after understanding procedure risks.

Health Privacy Code

Guidelines ensuring patient privacy in health information exchange.

Illegal Access

Unauthorized entry into computer data systems.

Data Interference

Unauthorized alteration or destruction of computer data.

Illegal Interception

Unauthorized capturing of data during transmission.

Public Health Exception

Disclosure permitted for public health benefits.

Legal Order Exception

Disclosure allowed by court order.

Written Waiver

Patient's written consent to disclose information.

Medical Treatment Exception

Disclosure for ongoing treatment with de-identification.

Secure Handling of Patient Data

Storing patient records securely, both physical and digital.

Discretion in Communication

Discussing patient info only with involved healthcare staff.

Patient Record Review Process

Steps for reviewing patient records through PHIE.

Clear Explanation

Technologists must explain procedures and risks clearly.

Patient Understanding

Patients should have opportunities to ask questions.

Documenting Consent

Recording informed consent in medical records.

PHIE System

Framework for health information exchange in the Philippines.

Competent Court

Authority that can issue legal orders for information.

Health Information Processing

Handling of health data by authorized entities.

Legitimate Access

Authorized individuals allowed to view patient records.

Privacy Guidelines

Procedures ensuring protection of patient privacy.

Informed Consent

Patient agreement to proceed with a procedure.

Cultural Competence

Understanding cultural differences in patient care.

Cultural Sensitivity

Respecting diverse cultural beliefs in healthcare.

Language Barriers

Challenges in communication due to language differences.

Professional Interpreters

Individuals who facilitate communication between languages.

Culturally Sensitive Care

Respecting patient preferences while educating them.

Documentation

Recording patient care details for legal compliance.

Procedure Details

Specifics about imaging procedures and patient positioning.

Patient Reactions

Documenting any adverse reactions during procedures.

Equipment Used

Details on imaging equipment and settings applied.