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  2. Healthcare Effectiveness Data and Information Set - Wikipedia

    en.wikipedia.org/wiki/Healthcare_Effectiveness...

    Most HEDIS data is collected through surveys, medical charts and insurance claims for hospitalizations, medical office visits and procedures. Survey measures must be conducted by an NCQA-approved external survey organization. Clinical measures use the administrative or hybrid data collection methodology, as specified by NCQA.

  3. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    Under Canadian federal law, the patient owns the information contained in a medical record, but the healthcare provider owns the records themselves. [29] The same is true for both nursing home and dental records. In cases where the provider is an employee of a clinic or hospital, it is the employer that has ownership of the records.

  4. Periodontal charting - Wikipedia

    en.wikipedia.org/wiki/Periodontal_charting

    Recording and Interpretation of Periodontal Charting Data. Once measurements are obtained, they are systematically documented in a periodontal chart, which typically includes columns for tooth number, probing depth, gingival margin, bleeding on probing, plaque index, tooth mobility, and furcation involvement.

  5. Medical billing - Wikipedia

    en.wikipedia.org/wiki/Medical_billing

    Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.

  6. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient's current presentation, such as: Vital signs are often already included in the chart. However, it is an important component of the SOAP note as well. [13] Vital signs and measurements, such as weight.

  7. Clinical audit - Wikipedia

    en.wikipedia.org/wiki/Clinical_audit

    Sample sizes for data collection are often a compromise between the statistical validity of the results and pragmatical issues around data collection. Data to be collected may be available in a computerised information system, or in other cases it may be appropriate to collect data manually or electronically using data capture solutions such as ...

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  9. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    Accessibility: Data items should be easily obtainable and legal to collect. Comprehensiveness: All required data items are included. Ensure that the entire scope of the data is collected and document intentional limitations. Consistency: The value of the data should be reliable and the same across applications. Currency: The data should be up ...

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