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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.
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1] Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology
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]
Each day large amounts of data are gathered by electronic health records. Because health care information systems are not compatible among themselves in general, structured data cannot easily be exchanged in between different institutions. [3] Only a small part of all medical forms are openly available.
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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.