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Typical data types which are often found within a CDR include: clinical laboratory test results, patient demographics, pharmacy information, radiology reports and images, pathology reports, hospital admission, discharge and transfer dates, ICD-9 codes, discharge summaries, and progress notes. [1]
A practitioner typically asks questions to obtain the following information about the patient: Identification and demographics: name, age, height, weight. The "chief complaint (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
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.
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.
The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...
Version 3.3.8 included the ability to support ICD-10, and all prior versions of AHLTA were phased out. However, DoD health professionals continued to find AHLTA to be difficult to use, slow, and frequently subject to crashing, and in 2013 DoD began taking bids for a $4.3 billion, 10-year contract to overhaul the system. [ 1 ]
The Patient-Reported Outcomes Measurement Information System [1] (PROMIS) provides clinicians and researchers access to reliable, valid, and flexible measures of health status that assess physical, mental, and social well–being from the patient perspective. PROMIS measures are standardized, allowing for assessment of many patient-reported ...
Step 1: Patient Registration [4] The process begins when a patient schedules an appointment. For new patients, this involves gathering essential information, including their medical history, insurance details, and personal data. For returning patients, the focus is on updating records with the latest reason for the visit and any changes to ...