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Seeing that each patient's medical record is complete, kept confidential, and safeguarded from individuals not involved with the medical care of the patient are primary responsibilities. [ 4 ] A RHIA certification is a preferred qualification for positions including health information management director, clinical documentation improvement ...
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.
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.
Electronic records, also often referred to as digital records, are those records that are generated with and used by information technology devices. Classification of records is achieved through the design, maintenance, and application of taxonomies , which allow records managers to perform functions such as the categorization, tagging ...
A clerk is a white-collar worker who conducts record keeping as well as general office tasks, or a worker who performs similar sales-related tasks in a retail environment. The responsibilities of clerical workers commonly include record keeping , filing, staffing service counters, screening callers, and other administrative tasks. [ 1 ]
The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation ...
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