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HRHIS is a human resource for health information system for management of human resources for health developed by University of Dar es Salaam college of information and communication technology, Department of Computer Science and Engineering, for Ministry of Health and Social Welfare (Tanzania) and funded by the Japan International Cooperation ...
Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient's current presentation, such as: Vital signs are often already included in the chart. However, it is an important component of the SOAP note as well. [13] Vital signs and measurements, such as weight.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
The Healthcare Information and Management Systems Society (HIMSS) is an American not-for-profit organization dedicated to improving health care in quality, safety, cost-effectiveness and access through the best use of information technology and management systems. It was founded in 1961 as the Hospital Management Systems Society.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]