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A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
Electronic health records flow chart. Clinical Data Repository/Health Data Repository (CDHR) is a database that allows for the sharing of patient records, especially allergy and pharmaceutical information, between the Department of Veteran Affairs (VA) and the Department of Defense (DoD) in the United States.
The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [6][7] In contrast, a ...
Clinical decision support system. A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow.
Donabedian model. The Donabedian model is a conceptual model that provides a framework for examining health services and evaluating quality of health care. [1] According to the model, information about quality of care can be drawn from three categories: “structure,” “process,” and “outcomes." [2] Structure describes the context in ...
Revenue cycle management. Revenue cycle management (RCM) is the process used by healthcare systems in the United States and all over the world to track the revenue from patients, from their initial appointment or encounter with the healthcare system to their final payment of balance. It is a normal part of health administration.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
A medical scribe's primary duties are to follow a physician through their work day and chart patient encounters in real-time using a medical office's electronic health record (EHR) and existing templates. Responsibilities will vary with the scribe’s department rules. Medical scribes generate referral letters for physicians, book appointments ...
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