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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 physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law. [26]
Theoretically, free software such as GNU Health and other open source health software could be used or modified for various purposes that use electronic medical records i.a. via securely sharing anonymized patient treatments, medical history and individual outcomes (including by common primary care physicians).
There may be additional restrictions in place on who can actually request a certified copy, such as immediate family or someone with written authorization. [5] Certified copies are usually much more expensive than uncertified copies. Some states have started making vital records available online for free. [6]
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
The new Archival Records became open to unlimited access by the general public with all requests for information to such records responded by providing a copy of the entire file. Those seeking these records were required to pay a fee, whereas the "Non-Archival Records", that is, the bulk of MPRC's holdings, are provided free of charge.
Vital registration systems that include medical certification of the cause of death captured about 18.8 million deaths of an estimated annual total of 51.7 million deaths in 2005, which is the latest year for which the largest number of countries reported deaths from a vital registration system.
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 ...
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