Key Terms
Health record
Collection of subjective and objective clinical information about a patient's physical and mental health.
Definition
The process of releasing health record information; critical for quality care, research, and billing.
Requires
Accurate exchange of patient information across an interlinked system where all stakeholders access the same data.
Memory trick
EMR = Medical = stays at the Medical office. EHR = Health = involves a whole team of Health professionals.
Interoperability
Ability to share patient information across multiple healthcare systems in digital format.
Advance directive
Legal document listing patient's wishes regarding life-sustaining medical treatments.
Medical power of attorney
Legal document identifying who makes medical decisions when the patient cannot.
Consent forms
Patient signs to allow the facility to treat them and to share information with pharmacies, insurance companies, and gov
Age of majority
Defined by each U.S. state; age at which a person can make their own decisions including healthcare decisions.
Who owns the record itself
The provider, practice, or facility that created it (per ONC, 2018; under federal guidelines).
Who owns the information IN the record
The patient.
How patients access it
Must request access; usually required in writing after consent forms are signed.
EHRs can be subpoena duces tecum
Court-ordered to be produced, years after the original encounter.
If an error is found
Correct it immediately. Most facilities require noting the error and then documenting the correct information.
Includes
Posture, gait, eye contact level, gestures, facial expressions.