Chapter 7 Medical Records and Informed Consent Flashcards Preview

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Flashcards in Chapter 7 Medical Records and Informed Consent Deck (14)
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5 Cs of documentation

- concise
- complete
- clear and legibly written
- correct
- chronologically ordered


medical record

A collection of data record when a patient seeks medical treatment


Purpose of medical records

- required by licensing authorities
- provide documentation of patients care
- provide a foundation for managing a pts health care
- legal document
- clinical data for education, research and statistical tracking


Correction in a medical chart

draw a line through the error so that it may still be read, initial, date and time. In some cases you must get a witness.


doctrine of professional discretion

a principle under which a physician can exercise judgement as to whether to show patients who are being treated for mental or emotional conditions their records. Disclosure depends on whether, in the physicians judgment such patients would be harmed by viewing the records.


Routine release of information

-Insurance claims
- transfer to another physician
- use in a court of law


fiduciary duty

a physician obligation to his or her patient, based on trust and confidence.


Guidelines for releasing information due to a subpoena

- check name on subpoena
- verify carbon copy is the same as original
- verify trial date and time
- notify physician of subpoena
- make sure all records are complete
- document number of pages you photocopied
- offer sworn testimony regarding the record.


confidentiality of alcohol and drug abuse patient records

a federal statute that protects patients with histories of substance abuse regarding the release of information about treatment



permission from a person, either expressed or implied, for something to be done by another


doctrine of informed consent

the legal basis for informed consent, usually outlined in a states medical practice acts.


People who cannot give Informed consent

- minors
- mentally incompetent
- speak limited or no english


Good Samaritan Acts

state law 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


Health information technology

the application of information processing, involving both computer hardware and software, that deals with the storage,retrieval sharing and use of health care information, data and knowledge for communication and decision making.