Ethics Chapter 7

Medical record

A collection of data recorded when a patient seeks medical treatment

Addendum

A significant change or addition to the electronic health record (EHR).

Concise, complete, clear, correct, chronological

The 5 C's of entries to medical records.

Doctrine of professional discretion

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

Fiduciary duty

A physicians obligation to his or her patient, based on trust and confidence.

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.

Consent

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 state's medical practice acts.

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.

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.