Handling of information disclosed in a trusted relationship, such as clinician-to-patient, regarding disclosure to only those who need to know
confidentiality
Data related to a person or group of people - can include name, date of birth, address, phone number, and email address
demographics
Period (planned or unplanned) in which the EHR is not fully accessible
downtime
The electronic version of a patient’s medical history maintained by a provider or providers over time
electronic health record (EHR)
The electronic version of a patient’s chart or medical record. It captures data for care provided by a provider or during a hospital stay.
electronic medical record (EMR)
Factual, Accurate, Complete and Concise, Timely
FACT
Federal law which created a national standard to protect sensitive patient health information from being disclosed or released without the patient’s informed consent
HIPAA
Occurs when two or more professions work together to achieve a common goal - for example, when a nurse works with a physical therapist to increase a patient’s walking ability
interprofessional
Improper, negligent, or illegal professional activity by a healthcare professional
malpractice
Represents facts or observations
objective
Data that comes from opinions, perceptions, or experiences reported by the patient
subjective
