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A range of software vendors offer these systems at an enterprise level (i.e. targeted at managing all documents and records within an enterprise). [1] These vendors have historically provided electronic document management systems and have acquired smaller records management system companies. The seamlessness of the integration and the original ...
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]
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 ...
Names; All geographical identifiers smaller than a state, except for the initial three digits of a zip code if, according to the current publicly available data from the U.S. Bureau of the Census: the geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; the initial three digits of a zip code for all such geographic units ...
Clinical Quality Language (CQL) is a ANSI certified [15] clinically focused high-level expression language standard curated by Health Level 7. [16] It is designated for clinical knowledge sharing in the domains of electronic clinical quality measurement and clinical decision support .
An example of a data-integrity mechanism is the parent-and-child relationship of related records. If a parent record owns one or more related child records all of the referential integrity processes are handled by the database itself, which automatically ensures the accuracy and integrity of the data so that no child record can exist without a parent (also called being orphaned) and that no ...
The terms EHR, electronic patient record (EPR) and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. [6] The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations.
Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator. [24] Under data protection legislation, the responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility.