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13 Cards in this Set

  • Front
  • Back
credibility gap
an apparent disparity between what is said or written and the actual facts
credible
believable or worthy of belief
disclosed
made known
doctrine of professional discretion
mean that a physician may determine, based on his or her best judgment, if a patient with mental or emotional problems should view the medical record
Electronic medical record EMR
EMTAKA a section of cobra dealing with patient dumping
encryptions
scrambling and encoding information before sending it electronically
firewalls
software to prevent unauthorized users
medical record
all the written and computer generated documentation relating to a patient
microfiche
miniaturized photograph of records
open-record laws
state freedom of information laws that grant public access to records maintained by state agencies
public health services act
protects patients who are receiving treatment for drug and alcohol abuse
subpoenaed
court order for a person or documents to appear in court
timeliness of documentation
all entries into a medical record should be made as soon as they occur or as soon as possible afterward