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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.
PCMS store large amounts of medical records, and hold the personal data of many individuals. These have become critical to the efficiency of storing medical information because of the high volumes of paperwork, the ability to quickly share information between medical institutions, and the increased mandatory reporting to the government. [1]
The FTC filed a complaint against medical testing laboratory LabMD, Inc. alleging that the company failed to reasonably protect the security of consumers’ personal data, including medical information. The FTC alleged that in two separate incidents, LabMD collectively exposed the personal information of approximately 10,000 consumers.
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]
Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records.The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements to doctors who fail to use ...
Individuals have the broad right to access their health-related information, including medical records, notes, images, lab results, and insurance and billing information. [48] Explicitly excluded are the private psychotherapy notes of a provider and information gathered by a provider to defend against a lawsuit.
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.
Information from or copies of records may be released only to authorized individuals, and the hospital shall ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records shall be released by the hospital only in accordance with federal or state laws, court orders, or subpoenas. (4) Content of record.