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14 Cards in this Set
- Front
- Back
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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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Code of ethics
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A statement of ethical principles regarding business practices and professional behavior
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Confidentiality
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A legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure
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Custodian of Health Records
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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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Electronic Health Record
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A computerized record of health information and associated processes
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Health Information
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The data generated and collected as a result of delivering care to a patient
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Health Informatics and Information Management (HIIM)
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The individuals responsible for managing healthcare data and information in paper or electronic form and controlling its collection, access, use, exchange, and protection through the application of health information technology
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Health Record
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Individually identifiable data, in any medium, that are collected, processed, stored, displayed, and used by healthcare professionals; documents the care rendered to the patient and the patient's healthcare status
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Hybrid Health Record
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A health record that uses a combination of paper and electronic formats
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The Joint Commission
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An agency that develops standards for healthcare organizations and certifies healthcare organizations based on adherence to those standards
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Ownership
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In healthcare, the person to whom the health records belongs; traditionally the healthcare provider
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Privacy
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The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information
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Security
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Means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss
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Security
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The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems
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