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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.
Continuity of Care Document - The Continuity of Care Document (CCD) represents 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. The primary use case for the CCD is to provide a snapshot in time containing the germane ...
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Epic primarily develops, manufactures, licenses, supports, and sells a proprietary electronic medical record software application, known in whole as 'Epic' or as Epic EMR. The company's healthcare software is centered on its Chronicles database management system. Epic's applications support functions related to patient care, including ...
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]
Sample view of an electronic health record. An electronic health record (EHR) also known as an electronic medical record (EMR) or personal health record (PHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings.
The JKL Healthcare System was one of the first successful implementers of EMR using the Epic System, and they became a model site for other healthcare systems. JKL Healthcare received the Davies Award in September 2004, which is the most prestigious award in the IT industry for its implementation of the most comprehensive EMR system in the US. [2]
Claims Attachments – a Standard Healthcare Attachment to augment another healthcare transaction; Functional Specification of Electronic Health Record (EHR) and Personal Health Record (PHR) systems – a standardized description of health and medical functions sought for or available in such software applications