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Medical translation is the practice of translating various documents —training materials, medical bulletins, drug data sheets, etc.—for health care, medical devices, marketing, or for clinical, regulatory, and technical documentation. Most countries require that companies and organizations translate literature and labeling for medical ...
This report is also referred to by many as a "medical record". Each specific transcribed record or report, with its own specific date of service, is then merged and becomes part of the larger patient record commonly known as the patient's medical history. This record is often called the patient's "chart" in a hospital setting.
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 ...
A subpoena duces tecum (pronounced in English / səˈpiːnə ˌdjuːsiːz ˈtiːkəm / sə-PEE-nə DEW-seez TEE-kəm), or subpoena for production of evidence, is a court summons ordering the recipient to appear before the court and produce documents or other tangible evidence for use at a hearing or trial. In some jurisdictions, it can also be ...
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records.The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements to doctors who fail to use ...
Medical informatics introduces information processing concepts and machinery to the domain of medicine. Health informatics is the study and implementation of computer structures and algorithms to improve communication, understanding, and management of medical information. [1] It can be viewed as a branch of engineering and applied science.
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 ...
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