The medical records of the patients are the documents that chart the details of a patient stay while in the hospital. This piece of document is one of the most essential to the patient because it contains his/her information. Each and every physician who comes in contact with the patient is to reference the proper results from the consultation or care given.
Mainly in health care settings, medical terminology is preferred because it helps to enable physician and professionals of the medical field to communicate efficienty regardless of state, community, facility, or profession.
Confidentiality is a must when regarding anyone who works medical terminology and in general, in the medical profession. Meaning that all information regarding a patient is to be kept confidential. Legally and morally, its your responsibility to with hold information unless, through proper authorization, the patient has consented.
The Health Insurance Portability and Accountability Act of 1996 ensures that patients are provided with protection of their records and health information.