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A medical scribe is an allied health paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations.They also locate information and patients for physicians and complete forms needed for patient care.
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
An individual who performs medical transcription is known as a medical transcriber (MT) or a Medical Language Specialist (MLS). The equipment used is called a medical transcriber, e.g., a cassette player with foot controls operated by the MT for report playback and transcription.
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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
A medical assistant, also known as a "clinical assistant" or healthcare assistant in the US [1] is an allied health professional who supports the work of physicians, nurse practitioners, physician assistants and other health professionals, usually in a clinic setting. Medical assistants can become certified through an accredited program.
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