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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.
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]
The ISO 15489-1: 2001 standard ("ISO 15489-1:2001") defines records management as "[the] field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records, including the processes for capturing and maintaining evidence of and information about business activities and ...
The adoption of electronic medical records refers to the recent shift from paper-based medical records to electronic health records (EHRs) in hospitals. The move to electronic medical records is becoming increasingly prevalent in health care delivery systems in the United States , with more than 80% of hospitals adopting some form of EHR system ...
Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from an EMR readily visible and accessible for consumers. [ citation needed ] Some EMR systems automatically monitor clinical events, by analyzing patient data from an electronic health record to predict, detect and potentially prevent ...
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A receipt (also known as a packing list, packing slip, packaging slip, (delivery) docket, shipping list, delivery list, bill of the parcel, manifest, or customer receipt) is a document acknowledging that a person has received money or property in payment following a sale or other transfer of goods or provision of a service.