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A release of information (ROI) department or division is found in the majority of hospitals. In the United States, HIPAA [1] and state guidelines strongly direct the rules and regulations of patient information. ROI departments perform such tasks as obtaining patient consent, certifying medical records, and deciding what information can be ...
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for ...
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [14] 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 term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.
The records management phase of the records life-cycle consists of: creation; classification; maintenance; disposition; Creation occurs during the receipt of information in the form of records. Records or their information is classified in some logical system. As records are used they require maintenance.
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Another issue of great interest to records managers is the impact of the internet and related social media, such as wikis, blogs, forums, and companies such as Facebook and Twitter, on traditional records management practices, principles, and concepts, since many of these tools allow rapid creation and dissemination of records and, often, even ...
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