Mindblown: a blog about philosophy.

Something written in the medical record. Certain members of the health care team, such as physicians, nurses, respiratory therapists, physical therapists, etc., are permitted by the hospital to write in the medical record. Each person doing so follows a certain protocol, which includes dating the written information and authenticating (signing) it (see authenticate). Customarily, a…

The individual in a long-term care facility (LTCF) assigned the responsibility of maintaining medical records on all patients. Note that this term applies to the duty, not to the qualifications, of the individual.  

A person who extracts a specific predetermined array of information from a medical record, usually on a pre-coded form to be used as input into a hospital discharge abstract system.  

In a medical school setting, an official document setting forth the policies under which patient services are rendered by medical school faculty physicians, the method of obtaining reimbursement, and the disposition of the funds obtained for such services. The detail of procedures is usually covered in the document.  

A proprietary system for carrying out occurrence screening; a method for detecting cases in which there was a possible quality problem. Its author is Joyce W. Craddick, MD, president of Medical Management Analysis Consulting and Education Services, Inc., of Auburn, California.  

Medical information that has been evaluated by experts and converted into useful medical concepts and options. A medical laboratory technician trained in an associate degree (AD) program. An allied health professional for whom the American Medical Association’s Committee on Allied Health Education and Accreditation (CAHEA) has accredited education programs.  

A California statute enacted in the mid-1970s which has been proposed as a model for malpractice reform. Its provisions include caps on noneconomic damages; elimination of joint and several liability, and instead hold defendants liable only in proportion to their degree of fault; offsets by awards from collateral sources; limits on statutes of limitations; and…

An allied health professional for whom the American Medical Association’s Committee on Allied Health Education and Accreditation (CAHEA) has accredited education programs.  

A physician, usually employed by the hospital, who serves as the administrative head of the medical staff. “Medical director” tends to be the title for the chief of staff when that person is a paid hospital employee. The title may also be “vice president for medical affairs” or something similar. This term is discussed further…

At the specific order of or under the supervision of a physician. In the context of an emergency medical services system (EMS or EMSS), medical direction means physician responsibility for the development, implementation, and evaluation of the clinical aspects of the system. Physician input to and overseeing of policies, protocols, medical procedures, training, and quality…