medical records
Health history documentation
Medical records are the documents containing a patient's health history, diagnoses, treatments, and test results.
They follow a person through the healthcare system, enabling continuity of care: The hospital requested her medical records from her previous doctor.
Access to one's own medical records is a legal right in most jurisdictions, though obtaining them often requires navigating bureaucracy.
Medical privacy statute
- confidentialityQuality of protecting secrets
- data protectionSecuring sensitive information
- encryptionConverting data into code
- patient rightsLegal protections for care recipients
access control · audit trail · de-identification · security · redaction · sensitive information · need-to-know · amendment rights
Indicators of disease
- prognosisPredicted disease course
- assessmentFormal evaluation of worth
- evaluationDetermining worth or quality
- screeningEvaluative selection process
laboratory · imaging · radiology · biopsy · differential · patient history · physical examination · test results
- EHRDigital patient documentation
- EMRDigital health documentation system
- patient portalOnline medical account access
- interoperabilityCross-platform functional harmony
digitization · scanning · archiving · storage · retrieval · transcription · templates · documentation
Medical dispensing authorization
- dosageMeasured medicine amount
- therapyCurative mental treatment
- rehabilitationRecovery from injury/addiction
- interventionPurposeful involvement to change course
regimen · surgery · chemotherapy · radiation · dialysis · vaccination · discharge summary · care plan
Writ requiring testimony
- evidenceFacts supporting truth
- litigationLegal dispute process
- malpracticeHarmful professional negligence
- consent formWritten agreement to proceed
deposition · discovery · testimony · affidavit · release form · authorization · retention · guardianship
Statements of truth
- coverageExtent of inclusion
- reimbursementPayment for incurred expenses
- preauthorizationPermission obtained beforehand
- copaymentPatient's fixed healthcare charge
deductible · itemized bill · provider · payer · Medicare · Medicaid · eligibility · enrollment
HIPAA
Medical privacy statute
- confidentialityQuality of protecting secrets
- data protectionSecuring sensitive information
- encryptionConverting data into code
patient rights · access control · audit trail · de-identification · security · redaction · sensitive information · need-to-know · amendment rights
symptoms
Indicators of disease
- prognosisPredicted disease course
- assessmentFormal evaluation of worth
- evaluationDetermining worth or quality
screening · laboratory · imaging · radiology · biopsy · differential · patient history · physical examination · test results · bloodwork
paper charts
- EHRDigital patient documentation
- EMRDigital health documentation system
- patient portalOnline medical account access
interoperability · digitization · scanning · archiving · storage · retrieval · transcription · templates · documentation · legibility
prescription
Medical dispensing authorization
- dosageMeasured medicine amount
- therapyCurative mental treatment
- rehabilitationRecovery from injury/addiction
intervention · regimen · surgery · chemotherapy · radiation · dialysis · vaccination · discharge summary · care plan · follow-up
subpoena
Writ requiring testimony
- evidenceFacts supporting truth
- litigationLegal dispute process
- malpracticeHarmful professional negligence
consent form · deposition · discovery · testimony · affidavit · release form · authorization · retention · guardianship · custody
claims
Statements of truth
- coverageExtent of inclusion
- reimbursementPayment for incurred expenses
- preauthorizationPermission obtained beforehand
copayment · deductible · itemized bill · provider · payer · Medicare · Medicaid · eligibility · enrollment · denied claim
- medical aiddoctor, surgeon, hospital, clinic, ambulance service
- medical recordschart, patient charts, patient chart, health data, EMR
- private dataSSN, passwords, password, PII, PHI
- VA HealthcareVA benefits, VA hospitals, veteran healthcare, veteran care, veteran benefits
- workplace privacyprivacy policies, privacy policy, personnel files, confidentiality, personal data
- HIPAAHIPAA, PHI, business associate, compliance officer, OCR
medical recordsbilling statements
Records of charges due
financial records · criminal records · legal documents · tax records · academic transcripts
record, medicine, recording, records, recorded, medical, recorder, medication, medicinal