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The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
Reputational damage caused by poor records management has demonstrated that records management is the responsibility of all individuals within an organization. An issue that has been very controversial among records managers has been the uncritical adoption of electronic document and records management systems. Impact of internet and social media
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.
Seeing that each patient's medical record is complete, kept confidential, and safeguarded from individuals not involved with the medical care of the patient are primary responsibilities. [ 4 ] A RHIA certification is a preferred qualification for positions including health information management director, clinical documentation improvement ...
Records management professionals in designing comprehensive and effective records management programs. The principles identify the critical hallmarks of information governance, which Gartner describes as an accountability framework that "includes the processes, roles, standards, and metrics that ensure the effective and efficient use of ...
Case management focuses on delivering personalized services to patients to improve their care, and involves four steps: Referral of new patients (perhaps from another service if the client has relocated to a new area out of previous jurisdiction, or if client no longer meets the target of previous service, such as requiring a greater level of ...
President-elect Trump has finished making selections for the top public health roles in his incoming administration after he issued a flurry of nominations late Friday and tapped a leader for the ...
The terms EHR, electronic patient record (EPR) and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. [6] The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations.