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CHAPTER 13 - THE MEDICAL RECORD

Across
An individual's aggregate electronic health record that is created and gathered cumulatively across more than one health care organization
This rule within HIPAA protects information from invasion, accidental disclosure or loss
This can be an indicator of exposure to environmental hazards or toxins
Reason for patient's visit
A collection of medical records compiled and maintained by an individual
This person must keep track of who has access to protected health information within a facility
Required in filing numerically
The "A" in SOAP stands for this
Problem-oriented medical record
Includes prescriber, the med name, dose, frequency, site/route, time given, observation, & patient's response
Measures that indicate a practice is actually using EMR/EHR.
This privacy rule provides standards for patients' confidential, personal information.
Is not obvious or cannot be proven
Recording observations, subjective/objective data, diagnostic information, treatments, & other pertinent data
Societal group patients identify themselves with
Refers to filing according to date
Down
The patient's chart belongs to this person or entity
Can indicate that a patient has financial support for treatment
This system is similar to SOAP
Breakdown of drugs currently prescribed to a patient
These medications don't need a prescription
Is obvious or can be proven with evidence
Data that includes patient name, SSN, DOB, spouse's name, address, work/home #, insurance, emergency contact
Chronological record detailing patient's progress during treatment
A provider sends a patient to a specialist with this
Most filing systems are based directly or indirectly on this arrangement
Electronic health record that is "handled" through a single organization involved in the individual's care