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  2. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]

  3. Release of information department - Wikipedia

    en.wikipedia.org/wiki/Release_of_Information...

    A release of information (ROI) department or division is found in the majority of hospitals. In the United States, HIPAA [1] and state guidelines strongly direct the rules and regulations of patient information. ROI departments perform such tasks as obtaining patient consent, certifying medical records, and deciding what information can be ...

  4. Adoption of electronic medical records in U.S. hospitals

    en.wikipedia.org/wiki/Adoption_of_Electronic...

    The adoption of electronic medical records refers to the recent shift from paper-based medical records to electronic health records (EHRs) in hospitals. The move to electronic medical records is becoming increasingly prevalent in health care delivery systems in the United States , with more than 80% of hospitals adopting some form of EHR system ...

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    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.

  6. List of abbreviations for medical organisations and personnel

    en.wikipedia.org/wiki/List_of_abbreviations_for...

    Mobile army surgical hospital (US) MedPAC: Medicare Payment Advisory Commission: MD: Doctor of Medicine: MLA: Medical laboratory assistant: MT: Medical technologist: MLT: Medical laboratory technician MOH: Ministry of Health (various countries) MRCP: Membership of the Royal College of Physicians: MRCS: Membership of the Royal College of ...

  7. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [14] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.

  8. Chesapeake Regional Information System for our Patients

    en.wikipedia.org/wiki/Chesapeake_Regional...

    In 2006, CRISP began at a Spring meeting between John Erickson and the CIOs of Maryland's three largest hospital systems, asking how to make medical records for seniors available when they visited the hospital. By 2008, CRISP had partnered with MHCC to plan an HIE for Maryland, the processed engaged dozens of healthcare stakeholders.

  9. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...