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HIM 115 Ch 7, 8, 9, 10 Key Terms

Advance Directive
A legal document that specifies an individuals healthcare wishes in the event that he or she has a temporary or permanent loss of competence.
Consent
1. A patients acknowledgement that he or she understands a proposed intervention, including that interventions risks, benefits, and alternatives; 2. A patients agreement that protected health information can be disclosed; the document that provides a record of the patients consent.
Do Not Resuscitate (DNR)
A specific type of advance directive in which an individual states that healthcare providers should not perform CPR if the individual experiences cardiac arrest or cessation of breathing.
Durable Power of Attorney (DPOA)
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.
Durable Power of Attorney for Healthcare Decisions (DPOA-HCD)
A legal instrument through which a principal appoints an agent to make healthcare decisions on the principals behalf in the event the principal become incapacitated.
Express Consent
Consent that is communicated through words, regardless of whether those words are written or spoken.
General Consent
A form that covers routine diagnostic procedures and medical treatment by hospital staff, as well as other activities such as release of information for treatment purposes and disposal of human tissue and body fluids.
Good Samaritan Statute
State law or statute that protects healthcare providers from liability for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident.
Implied Consent
Consent for medical treatment that is communicated through a persons conduct or some other means besides words.
Informed Consent
A type of consent in which the patient should have a basic understanding of which medical procedures or test may be performed as well as the risks, benefits, and alternatives for those tests or procedures.
Living Will
A document executed by a competent adult that expresses that individuals wishes to limit treatment measures when specific health-related diagnoses or conditions exist.
Power of Attorney (POA)
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.
Therapeutic Privilege
A doctrine that has historically allowed physicians to withhold information from patients in limited circumstances.
Uniform Health-Care Decisions Act (UHCDA)
A model law created in 1993 that provides that an individual may give an oral or written instruction to a healthcare provider that remains in force even after the individual loses capacity, and suggests decsision-making priority for that individuals surrogates.
Authentication
Verification of a records validity (that is, it is the record of the individual in question and it is what it puports to be) and, therefore, its reliability and truthfulness as evidence; also a security mechanism to validate the identity of a user in an electronic system.
Authenticity
The genuineness of a record, that it is what it puports to be; information is authentic if proved to be immune from tampering and corruption.
Business Record
A record that is made and kept in the usual course of business, at or near the time of the event recorded.
Completeness
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 by-laws.
Designated Record Set (DSR)
A group of records maintained by or for a covered entity encompassing medical records and billing records 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 abou individuals.
Joint Commission
An agency that develops standards for healthcare organizations and certifies healthcare organizations on the basis of adherence to those standards.
Legal Health Record (LHR)
The form of a health record that is the legal business record of the organization and serves as evidence in awsuits orother legal actions; what constitutes an organizations legal health record varies depending on how the organozation defines it.
Master Patient Index (MPI)
A patient-identifying directory that serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death.
Retention
A mechanism for storing records, providing for timely retrieval, and establishing the length of time that various types of records will be retained by the healthcare organization.
Statutes of Limitations
A statutory enactment that places time limits on certain claims.
Uniform Electronic Transaction Act (UETA)
Federal statute that provides a mechanism for indiiduals to deal with their property in the event of incapacity.
Uniform Photographic Copies of Business and Public Records as Evidence Act (UPA)
Federal statute, with state versions, that makes admissable as evidence the reproduction of any record that has been retained in the regular course of of business and kept by a process that accurately produces the original in any medium; supports the transaction from paper to electronc storage of information.
Affiliated Covered Entities
Legally separate covered entities, affiliated by common ownership or control; for purposes of the Privacy Rule, these legally separate entities may refer to themselves as a single covered entity.
Covered Entities (CE)
Persons or organizations that must comply with the HIPAA Privacy and Security Rules; include healthcare providers, health plans, and healthcare clearinghouses.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
A law enacted by Congress on August 21, 1996, governing various aspects of health information; federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the decurity and privacy of health information.
Notice of Privacy Practices (NPP)
A statement (mandated by HIPAA Privacy Rule) issued by a healthcare organization that informs individuals of the uses and disclosures of patient-identifiable health information that may be made by the organization, as well as the individuals rights and the organizations legal duties with respect to that information.
Privacy Act of 1974
A law that requires Federal agencies to safeguard personally identifiable records and provides individuals with certain privacy rights.
Protected Health Information (PHI)
A term defined in the HIPAA Privacy Rule a “individually identifiable health information that is transmitted by electronic media, maintained in electronic medium, or transmitted or maintained in any other form or medium.”
Encryption
A technique used to ensure that data transferred from one location on a network to another are secure from eavesdropping or interception.
Security Officer or Chief Security Officer
An individual responsible for overseeing privacy policies and procedures.
Technical Safeguards
Security measures that are based on technology rather than on administration or physical security, including access control, unique user identification, automatic logoff, and encryption and decryption.

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