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Medicine /Medical Terminology: Medical Records & Documentation Part 3

Medical Terminology: Medical Records & Documentation Part 3

Medicine20 CardsCreated about 1 month ago

This deck covers key terms and concepts related to medical records and documentation, including definitions of common abbreviations, legal terms, and regulatory standards.

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Define: Rx (Prescription)

A written order from a healthcare provider for a specific medication or treatment for a patient. The pharmacist filled the Rx for the patient's pain medication.
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Key Terms

Term
Definition
Define: Rx (Prescription)
A written order from a healthcare provider for a specific medication or treatment for a patient. The pharmacist filled the Rx for the patient's pain m...
Define: Sx (Symptoms)
The signs or indications of a disease or condition as experienced by the patient. The patient reported several Sx including fatigue and shortness of b...
Define: Fx (Fracture)
A break in a bone that can result from trauma, overuse, or certain medical conditions. The X-ray confirmed a Fx of the patient's right wrist.
Define: Hx (History)
A record of a patient's past medical issues, treatments, and family history relevant to their current health. The physician reviewed the patient's Hx ...
Define: Informed Consent
A process in which a patient is educated about the risks and benefits of a procedure or treatment before agreeing to it. The patient signed the Inform...
Define: HIPAA (Health Insurance Portability and Accountability Act)
A U.S. law that provides privacy standards to protect patients' medical records and other health information. The clinic ensures compliance with HIPAA...
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Medical Terminology: Medical Records & Documentation Part 3
TermDefinition
Define: Rx (Prescription)
A written order from a healthcare provider for a specific medication or treatment for a patient. The pharmacist filled the Rx for the patient's pain medication.
Define: Sx (Symptoms)
The signs or indications of a disease or condition as experienced by the patient. The patient reported several Sx including fatigue and shortness of breath.
Define: Fx (Fracture)
A break in a bone that can result from trauma, overuse, or certain medical conditions. The X-ray confirmed a Fx of the patient's right wrist.
Define: Hx (History)
A record of a patient's past medical issues, treatments, and family history relevant to their current health. The physician reviewed the patient's Hx to identify potential risk factors.
Define: Informed Consent
A process in which a patient is educated about the risks and benefits of a procedure or treatment before agreeing to it. The patient signed the Informed Consent form prior to surgery.
Define: HIPAA (Health Insurance Portability and Accountability Act)
A U.S. law that provides privacy standards to protect patients' medical records and other health information. The clinic ensures compliance with HIPAA regulations to safeguard patient data.
Define: Confidentiality
The ethical principle of keeping patient information private and secure from unauthorized access. The healthcare provider emphasized the importance of Confidentiality in handling patient records.
Define: Privacy Rule
A component of HIPAA that establishes national standards for the protection of individuals' medical records and personal health information. The Privacy Rule ensures that patients' health information is kept secure.
Define: Security Rule
A HIPAA regulation that sets standards for safeguarding electronic protected health information (ePHI). The Security Rule mandates that healthcare providers implement measures to protect ePHI.
Define: Protected Health Information (PHI)
Any individually identifiable health information that is transmitted or maintained in any form, as protected by HIPAA. The clinic must ensure the security of Protected Health Information (PHI) to comply with regulations.
Define: Authorization
A patient's formal permission for a healthcare provider to use or disclose their health information for specific purposes. The patient provided Authorization for the release of their medical records.
Define: Legal Liability
The legal responsibility of healthcare providers to provide care that meets accepted standards, and to be accountable for any harm caused. The physician was aware of the Legal Liability involved in performing the procedure.
Define: Compliance
The process of adhering to laws, regulations, and guidelines relevant to healthcare practices and patient care. The facility implemented new policies to ensure Compliance with federal regulations.
Define: Risk Management
The identification, assessment, and prioritization of risks followed by coordinated efforts to minimize, monitor, and control the probability of unfortunate events. The hospital's Risk Management team worked to prevent potential liabilities.
Define: Medical Malpractice
A legal term referring to professional negligence by a healthcare provider that results in harm to a patient. The patient filed a claim for Medical Malpractice after receiving improper treatment.
Define: Standard of Care
The level of care and skill that a reasonably competent healthcare provider would provide in similar circumstances. The court evaluated whether the physician met the Standard of Care in the treatment provided.
Define: Documentation Errors
Mistakes or inaccuracies in medical records that can lead to miscommunication and negatively impact patient care. The audit revealed several Documentation Errors that needed correction.
Define: Addendum
An additional document added to a medical record to provide more information or clarification after the original entry was made. The physician submitted an Addendum to clarify the patient's treatment plan.
Define: Amendment
A formal change or correction made to a medical record to rectify inaccuracies or update information. The patient's Amendment to their medical history was approved by the provider.
Define: E-signature
An electronic signature that is used to sign documents in a digital format, providing authenticity and integrity to electronic records. The provider used an E-signature to approve the patient's treatment plan.