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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.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
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 ...
EHR systems are designed to store data accurately and to capture the state of a patient across time. It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is up-to-date, [5] accurate and legible. It also allows open communication between the patient and the provider, while providing ...
Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator. [24] Under data protection legislation, the responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility.
In 2019, the US Department of Health and Human Services Office for Civil Rights (OCA) promised to enforce patients’ right to access under HIPAA, using the Right of Access Initiative. There have currently already been two settlements with the OCA under the Right of Access Initiative, after companies failed to give patient medical records. [23]
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