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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 ...
The International Labour Organization's International Standard Classification of Occupations further notes: "Occupations included in this category require knowledge of medical terminology, legal aspects of health information, health data standards, and computer- or paper-based data management as obtained through formal education and/or ...
In business and project management, a responsibility assignment matrix [1] (RAM), also known as RACI matrix [2] (/ ˈ r eɪ s i /; responsible, accountable, consulted, and informed) [3] [4] or linear responsibility chart [5] (LRC), is a model that describes the participation by various roles in completing tasks or deliverables [4] for a project or business process.
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.
A medical scribe's primary duties are to follow a physician through their work day and chart patient encounters in real-time using a medical office's electronic health record (EHR) and existing templates. Responsibilities will vary with the scribe’s department rules.
Records managers are present in virtually every type of organization. The role can range from one of a file clerk to the chief information officer of an organization. Records managers may focus on operational responsibilities, design strategies and policies for maintaining and utilizing information, or combine elements of those jobs. [1]
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Medical transcription as it is currently known has existed since the beginning of the 20th century when standardization of medical records and data became critical to research. [1] [2] At that time, medical stenographers recorded medical information, taking doctors' dictation in shorthand. With the creation of audio recording devices, it became ...
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