General Medical Records
This is the term for communications that are protected and cannot be disclosed without patient consent.
What is privileged communication?
One advantage of electronic medical records is that they are this, making them easy to read.
What is legible?
Observations made by this group should never be included in medical records.
Who are health care workers?
This must be verified before faxing confidential information.
What is the receiver's fax number?
This should not be left on a printer or copier to protect patient confidentiality.
What are confidential documents?
These belong to health care providers, but patients can request access to them.
What are medical records?
A disadvantage of electronic medical records that involves high upfront costs.
What are hardware, software, and licensing costs?
Errors in medical records should never be erased with this material.
What is correction fluid or white out?
Faxed confidential information should always include this page for added security.
What is a cover sheet with a confidentiality statement?
When disposing of unneeded printouts of confidential information, this must be done instead of throwing them in the trash.
What is shredding?
This group of patients might not have access to their records to prevent worsening their condition.
Who are patients with mental illness?
This protective measure uses unique identifiers like fingerprints or passwords for access.
What are authentication methods?
These should surround subjective statements made by patients in medical records.
What are quotation marks?
When leaving a phone message for a patient, this should not be mentioned.
What is confidential information?
This should be removed from the copier in the event of a paper jam to maintain security.
What are the copies that caused the jam?
The appropriate way to correct an error in a medical record includes this specific action.
What is drawing a single line through the error, writing "error," initialing, and dating it?
his term refers to concerns about unauthorized individuals accessing EMRs.
What are confidentiality and security concerns?
Medical records must always be these three things to maintain their integrity as legal documents.
What are complete, legible, and timely?
After faxing confidential information, this follow-up action should be taken.
What is contacting the receiver to confirm receipt?
Unauthorized individuals in the area are a reason to avoid using these machines for confidential tasks.
What are copiers and printers?
According to federal and state laws, medical records must be kept for this range of years.
What is two to seven years?
One major benefit of EMRs is their ability to provide this kind of real-time access for multiple users.
What is simultaneous access?
When destroying old medical records, this method should be used.
What is shredding?
To maintain confidentiality on a phone call, this should be avoided if unauthorized individuals are present.
What is using the patient’s name?
When printing confidential information, these types of printers should be avoided.
What are shared printers?