Chapter Informatics And Information Management –

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Advance Directive
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a legal document that specifies an individual’s healthcare wishes in the event that he or she has a temporary or permanent loss of competence
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Consent
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a patient’s acknowledgement that he or she understands a proposed intervention, including the intervention’s risk, benefits, and alternatives; A patients agreement that health care information can be disclosed, the document provides a record of consent
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(DNR) Do Not Resuscitate order
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A specific type of advanced directive in which an individual states that healthcare providers should not perform CPR if the individual experiences cardiac arrest or cessation of breathing
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(DPOA) Durable Power of Attorney
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a power of attorney that remains in effect even after the principal is incapacitated; can be drafted to take effect only when the principal becomes incapacitated
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(DPOA-HCD) Durable Power of Attorney for healthcare decisions
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a legal instrument through which a principal appoints an agent to make healthcare decisions on the principal’s behalf in the event the principal becomes incapacitated
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Express consent
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consent that is communicated through words, regardless of whether those words are spoken or written
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General Consent
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a form that covers routine diagnostic procedures and medical treatment by hospital staff, as well as other activities such as release of information for treatments purposes and disposal of human tissue and body fluids consent
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(GINA) Genetic Information Nondiscrimination Act
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Federal legislation that prohibits discrimination by health insurers and employers based on genetic information
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Good Samaritan statute
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state law or statute that protects healthcare provides from liability for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident
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(HIPPA) Health Insurance Portability and Accountability Act
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a law enacted by Congress on 8/21/96, governing various aspects f health information; federal legislation enacted to provide continuity of health coverage, control fraud and abuse in HC, reduce HC costs, and guarantee the security and privacy of health information
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Implied consent
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consent for medical tx that is communicated through a person’s conduct or some other means besides words
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Informed consent
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a type of consent in which the patient should have a basic understanding of which medical procedures or tests may be performed as well as the risks, benefits, and alternatives for those tests or procedures
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(IRB) Institutional review board
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a committee of at least five members with varying backgrounds that determines the acceptability of proposed human subjects research in accordance with institutional policies, applicable law, and standards of professional practice and conduct
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Living Will
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a document executed by a competent adult that expresses the individual wishes to limit tx measures when specific health related dx or conditions exist
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Long Form
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in the context of human subjects research, a consent form that includes all of the informed consent requirements included in the Common Rule
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Non compos mentis
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Not of sound mind
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(PSDA) Patient Self Determination Act
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a law that became effective in 1991 requiring HC institutions that bill MCR and MCD for services to provide adult patients with information about the various types of advance directives
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(POA) Power of Attorney
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a legal instrument used by a principal(person) to grant legal authority to one or more agents to make certain legal and financial decisions on behalf of the principal
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Short Form
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Is a written document stating the elements of informed consent required by the common rule have been orally presented to and understood by the subject(s) or the subject’s legally authorized representative
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Therapeutic privilege
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A doctrine that has historically allowed physicians to withhold information from patients in limited circumstances
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(UAGA) Uniform Anatomical Gift Act
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An act that provides suggested standards for all aspects of organ donation, including who make anatomical gifts and hoe intent to make anatomical gifts should be expressed-designed to create uniformity in this area across all 50 states
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(UHCDA) Uniform Health-Care Decisions Act
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a model law created in 1993 that provides that an individual may give an oral or written instructions to a HC provider that remains in force even after the individual loses capacity, and suggest decision-making priority for that individual’s surrogates
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hybrid health record
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a health record that uses a combination of paper and electronic format
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Electronic health record
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a computerized record of health information and associated processes; an electronic record of health-related information on an individual that conforms to nationally recognized standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
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medicare
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– a program that provides healthcare services to qualified individuals
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meaningful use
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– a requirement per the American Recovery and Reinvestment Act for healthcare providers to receive Medicare and Medicaid incentive payments; emphasizes collection of electronic data in the electronic health record (EHR) and subsequent use of EHR functionalities for tracking, reporting, and patient-care purposes
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business record
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a record that is made and kept in the usual course of business; at or near the time of the event recorded
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legal health record
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the form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization’s legal health record varies depending on how the organization defines it
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designated record set
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– a group of records maintained by or for a covered entity encompassing medical records and billing record about individuals and enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan used, in whole or in part, by or for the covered entity to make decisions about individuals
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custodian/ custodian of health record
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– the person designated as responsible for the operational functions of the development and maintenance of the health record and who may certify through affidavit or testimony the normal business practices used to create and maintain the record
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Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA) –
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federal statue, with state versions, that make admissible as evidence the reproduction of any record that has been retained in regular course of business and kept by a process that accurately reproduces the original in any medium; supports the transition from paper to electronic storage of information
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joint commission
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an agency that develops standards for healthcare organizations and certifies healthcare organizations on the basis of adherence to those standards
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Conditions of Participation (CoP)
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the standards that govern providers receiving Medicare and Medicaid reimbursements
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Physician order
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a type of document within the health record that provides mandatory instructions regarding medical interventions such as treatments, ancillary medical services, tests and procedures, medications, or seclusion and restraint
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Liability
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a legal obligation or responsibility that may have financial repercussions if not fulfilled; an amount owed by an individual or organization to another individual or organization
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Authenticity
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the genuineness of a record that it is what it purports to be; information is authentic if proved to be immune from tampering and corruption
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authentication
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verification of a record’s validity and, therefore, it reliability and truthfulness as evidence; also a security mechanism to validate the identity of a user in an electronic system
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handwritten signatures
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completed in ink, the most common method of authenticating paper health record
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Rubber signature stamps
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a type of authentication for paper records; stamps must be used only by the person identified by the stamp in accordance with laws, standards, and regulations
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initials
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an authentication method for paper health records that may be permitted in lieu of a full signature as long as the initials are readily identifiable as the author’s through a signature legend on the same document
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metadata
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data about data, information about an electronic data element’s content
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electronic signatures
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technological corollary to the handwritten signature in the paper record
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digital signature
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a subset of e-signature technology
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Computer key
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a number unique to a specific individual for purposes of authentication
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Countersignature
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authentication by a second provider that signifies review and evaluation of the actions and documentation, including authentication, of a first provider
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Auto-authentication
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a process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specified time period results in authentication
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Accuracy
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the extent to which the information reflects the true, correct, and exact description of the care that was delivered with respect to both content and timing
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Authorship
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the origination or creation of recorded information attributed to a specific individual or entity acting at a particular time
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Abbreviations
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shortened form of a word or phrase
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Legibility
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an aspect of the quality of provider entries; if an entry cannot be read, it must be assumed that it cannot be used or was not used in the patient care process
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Amendment (addendum)
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a type of late entry in which information is added to support or clarify a previous entry
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Late entry
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entry documented in health record when a pertinent entry was missed or was not written in a timely manner
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Version management
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refers to how an organization handles the numerous versions that may exist of a document or collection of data
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Timeliness
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the completion of a health record within timelines established by legal and accreditation standards and by organizational policy and medical staff bylaws
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Completeness
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an element of a legally defensible health record; the health record is not complete until all its parts are assembled and the appropriate documents are authenticated according to medical staff bylaws
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Personal health records
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an electronic or paper health record maintained and updated by an individual for himself or herself
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Retention
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storage and retrieval of health records
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Disposition
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destruction transfer or loss of health records
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Master patient index (MPI)
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a patient identifying directory
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Retention schedule
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a timeline for records retention based on factors such as federal and state laws, statues of limitations, age of patient, competency of patient, accreditation standards, AHIMA recommendations and operational needs
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Destruction of records
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the act of breaking down the components of a health record into pieces that can no longer be recognized as parts of the original record; for example, paper records can be destroyed by shredding, and electronic record can be destroyed by magnetic degaussing
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Transfer of health records
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moving of a record from one medium to another or to another records custodian
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Uniform Electronic Transactions Act
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federal statute that makes electronic transactions as enforceable as paper transactions, removing barriers to electronic commerce and increasing trust associated with electronic business transactions
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Electronic Signature in Global National Commerce Act
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an act passed in 2000 that gives e-signatures the same legality as handwritten signatures where interstate commerce is involved and that provides guidance on how records may be stored and retained electronically

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