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Chapter 7
vocabulary
| Term | Definition |
|---|---|
| Addendum | A significant change or addition to the electronic health record (EHR) |
| 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. |
| Doctrine of professional discretion | A principal where a physician can exercise judgment as to whether to show patients who are being treated for mental/emotional conditions their records. Disclosure depends on the physicians judgment, some patients would be harmed by viewing the records. |
| Electronic health record (EHR) | A more comprehensive record than the EMR, focusing on the total health of the patient and traveling with the patient |
| Fiduciary duty | A physicians obligation to his or her patient, based on trust and confidence |
| 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 (HIT) | 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. |
| Medical Record | Collection of data recorded when a patient seeks medical treatment. |
| affirmative action | programs that use goals and quotas to provide preferential treatment for minority persons determined to have been underutilized in the past. |
| chemical hygiene plan | The standard for occupational exposures to hazardous chemicals in laboratories, which clarifies the handling of hazardous chemicals in medical laboratories. |
| clinical laboratory improvement act (CLIA) | also called CLIA federal statutes passed in 1988 that established minimum quality standards for all laboratory testing. |
| discrimination | prejudiced or prejudicial outlook, action, or treatment. |
| employment at will | a concept of employment whereby either the employee or the employee can end the employment at any time for any reason |
| General duty cause | A section of the Hazard Communication standard that states that any equipment that may pose a health risk must be specified as a hazard. |
| Hazard Communication Standard (HCS) | An OSHA standard intended to increase health care practitioners awareness of risks, to improve work practices and appropriate use of personal protective equipment, and to reduce injuries and illness in the workplace. |
| just cause | An employers legal reason for firing an employee |
| medical waste tracking act | the federal law that authorizes OSHA to inspect hazardous medical wastes and to cite offices for unsafe or unhealthy practices regarding these wastes. |
| Occupational Exposure to Bloods-borne Pathogen Standard | An OSHA regulation designed to protect health care workers from the risk of exposure to blood borne pathogens. |
| Occupational safety and health administration (OSHA) | Established by the occupational safety and Health Act , the Organization that is charged with writing and enforcing compulsory standards for health and safety in the workplace. |
| public policy | The common law concept of wrongful discharge when an employee has acted for the "common good". |
| Right to know laws | State laws that allow employees access to information about toxic or hazardous substances, employer duties, employee rights, and other workplace health and safety issues |
| Surety Bond | A type of insurance that allows employers, if covered, to collect up to the specified amount of the bond if an employee embezzles or otherwise absconds with business funds. |
| United National Globally Harmonized system of classification and labeling of chemicals (GHS) | Led to a 2012 revision of the Hazard Communication Standard in order to transform "right to know" to "right to understand" in line with GHS. |
| workers compensation | A form of insurance established by federal and state statutes that provides reimbursement for workers who are injured on the job. |
| Wrongful discharge | A concept established by precedent that says an employer risks litigation if he or she does not have just cause for firing an employee. |
| National childhood vaccine injury act | A federal law passed in 1986 that created a no-fault compensation program for citizens injured or killed by vaccines, as an alternative to suing vaccine manufactures and providers. |
| National Vaccine Injury Compensation Program (VICP) | A no-fault federal system of compensation for individuals or families of individuals injured by childhood vaccinations. |
| Prescribe | To issue a medical prescription for a patient |
| Small pox Emergency Personnel Protection Act (SEPPA) | A no fault program to provide benefits and or compensation to certain individuals, including health care workers and emergency responders, who are injured as the result of the administration of small pox countermeasures. including the small pox vaccine. |
| Unborn victims of violence act | Also called Laci and Conner's Act, a federal law passed in 2004 that provides for the prosecution of anyone who causes injury to or the death of a fetus in utero. |
| Vital statistics | Numbers collected for the population of live births, deaths, fetal deaths, marriages, divorces , induced terminations of pregnancy and any change in civil status that occurs during an individuals lifetime. |
| administer | to instill a drug into the body of a patient |
| Amendments to the older Americans act | A 1987 federal act that defines elder abuse, neglect, and exploitation, but does not deal with enforcement. |
| Autopsy | A postmortem examination to determine the cause of death or to obtain physiological evidence, as in the case of a suspicious death. |
| Child abuse prevention and Treatment act | A federal law passed in 1974 requiring physicians to report cases of child abuse and to try to prevent future cases. |
| Controlled substances Act | The federal law giving authority to the Drug Enforcement Administration to regulate the sale and use of drugs. |
| Coroner | A public official who investigates and hold inquests over those who die from unknown or violent causes; he or she may or may not be a physician, depending on state law. |
| dispense | to deliver controlled substances in some type of bottle, box, or other container to a patient. |
| Drug Enforcement Administration (DEA) | A branch of the U.S Department of Justice that regulates the sale and use of drugs. |
| Federalism | The sharing of power among national, state , and local governments. |
| Food and Drug Administration (FDA) | A federal agency within the Department of Health and Human Services that oversees drug quality and standardization and must approve drugs before they are released for public use. |
| Forensics | A Division of medicine that incorporates law and medicine and involves medical issues or medical proof at trials having to do with malpractice, crimes, and accidents. |
| medical examiner | A physician who investigates suspicious or unexplained deaths. |
| covered transactions | Electronic exchanges of information between two covered-entity business partners using HIPPA- mandated transactions standards, |
| Designated record set | records maintained by or for a HIPPA covered entity |
| Notice of Privacy Practices (NPP) | A written document detailing a health care providers privacy practices. |
| Treatment, payment, and healthcare operations (TPO) | HIPPA term for qualified providers, disclosure, of PHI to obtain reimbursement, and activities and transactions among entities. |
| Transaction and Code sets | A transaction refers to the transmission of information between two parties to carry out financial or administrative activities. A code set is any set of codes used to to encode data elements, sucha as tables of terms, medical concepts, medical diagnostic |
| Privacy Rule | Policies and procedures health care providers and their business associates put in place to ensure confidentially of electronic, written, and oral protected health information. |
| Security Rule | Security refers to those policies and procedures health care providers and their business associates use to protect electronically transmitted and stored PHI from unauthorized access. |
| National Identifier Standards | Provide unique identifiers (addresses) for electronic transmissions. |
| American recovery and reinvestment act (ARRA) | A 2009 act that made substantive change to HIPPA"'s privacy and security regulations. |
| breach | Any unauthorized acquisition, access, use, or disclosure of personal health information which comprises the security or privacy of such information. |
| Criminal Health Care Fraud Statute | A section of the united states code that prohibits fraud against any health care benefit program. |
| Electronic Health Record (EHR) | Contains the same information as any medical record, but in electronic form and is a collection of all the medical records for a single patient. |
| Electronic medical record (EMR) | Contains all patient medical records for one practice or one organization. |
| Encryption | The scrambling or encoding of information before sending it electronically. |
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