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a collection of data recorded when a patient seeks medical treatment
medical record
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a principle under which a physician can exercise judgment as to whether to show patients who are being treated for mental or emotional conditions their records. Disclosure depends on whether, in the physician's judgment, such patients would be harmed by viewing the records
doctrine of professional discretion
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a physician's obligation to his or her patient, based on trust and confidence
fiduciary duty
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a federal statue that protects patients with histories of substance abuse regarding the release of information about treatment
confidentiality of alcohol and drug abuse, patient records
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permission from a person, either expressed or implied, for something to be done by another
consent
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the legal basis for informed consent, usually outlined in a state's medical practice acts
doctrine of informed consent
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state laws protecting physicians and sometimes other health care practitioners and laypersons form charges of negligence or abandonment if they stop to help the victim of an accident or other emergency
good samaritan acts
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the application of information processing, involving both computer hardware and software, that deals with the storage, retrieval, sharing and use of health care information, data, and knowledge for communication and decision making
(HIT) health information technology
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contains the same information as any medical record, but in electronic form
(EHR) electronic health record
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