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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.
The Joint Commission Accreditation for Healthcare Organization (JCAHO) is a nonprofit organization that assesses quality at multiple levels by inspecting health care facilities for adherence to clinical guidelines, compliance with rules and regulations for medical staff skills and qualifications, review of medical records to evaluate care ...
CDA specifies the syntax and supplies a framework for specifying the full semantics of a clinical document, defined by six characteristics: [2] Persistence; Stewardship; Potential for authentication; Context; Wholeness; Human readability; CDA can hold any kind of clinical information that would be included in a patient's medical record ...
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
In cases in which a physician has difficulty explaining complicated medical concepts to a patient, that patient may be inclined to seek information on the internet. [8] A consensus exists that patients should have shared decision making, meaning that patients should be able to make informed decisions about the direction of their medical treatment in collaboration with their physician. [9]
There are many forms of PHI, with the most common being physical storage in the form of paper-based personal health records (PHR). Other types of PHI include electronic health records, wearable technology, and mobile applications. In recent years, there has been a growing number of concerns regarding the safety and privacy of PHI.
During the retention period, specimens are considered to be part of the medical record and must be kept under a CLIA accredited laboratory to ensure compliant handling and storage conditions. [ 25 ] [ 26 ] If a specimen is sent-out to a non-CLIA biorepository and recalled, the additional testing would not be in compliance. [ 25 ]