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A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information ...
Medical audit later evolved into clinical audit and a revised definition was announced by the NHS Executive: "Clinical audit is the systematic analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for the patient."
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.
In the 1900s, peer review methods evolved in relation to the pioneering work of Codman's End Result System [24] and Ponton's concept of Medical Audit. [25] Lembcke, himself a major contributor to audit methodology, in reviewing this history, notes the pre-emptive influence of hospital standardization promoted by the American College of Surgeons ...
The administration at Lenawee Medical Care Facility ... Service Employees International Union Healthcare Michigan is calling on the state of Michigan to audit the nursing home's finances to verify ...
This may enable increased flexibility, improved disease surveillance, better medical product safety surveillance, [32] better public health monitoring (such as for evaluation of health policy effectiveness), [33] [34] increased quality of care (via guidelines [35] and improved medical history sharing [36] [37]), and novel life-saving treatments.
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