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CHAPTER 13 - THE MEDICAL RECORD

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