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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 nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing ...
Not all documents are records. A record is a document consciously (consciously means that the creator intentionally keeps it) retained as evidence of an action. Records management systems generally distinguish between records and non-records (convenience copies, rough drafts, duplicates), which do not need formal management.
The same is true for both nursing home and dental records. In cases where the provider is an employee of a clinic or hospital, it is the employer that has ownership of the records. By law, all providers must keep medical records for a period of 15 years beyond the last entry. [30]
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 ...
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]
The Healthcare Information and Management Systems Society (HIMSS) was established in 1961 as the Hospital Management Systems Society (HMSS) by Edward J. Gerner and Harold E. Smalley. The first national convention was held in Baltimore in 1962, and the organization moved its headquarters to Chicago in 1964.
In the 1970s a growing number of commercial vendors began to market practice management and electronic medical records systems. Although many products exist, only a small number of health practitioners use fully featured electronic health care records systems.