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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.
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.
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.
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.
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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