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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.
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.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Until 1996, the Military Personnel Records Center operated through a complex system of paperwork forms with little computer automation. By the 1980s, serious complaints about the facility led the military service departments to develop procedures to hold their own records rather than have such records sent to the Military Personnel Records Center.
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [12] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
The meeting ended with paperwork. Another administrator had gathered together a set of medical records request forms requiring that Patrick’s parents provide proof of his death. In the adjacent room, their son was memorialized on the Recovery Works death wall. A death certificate would do, Holcomb said.
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