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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 ...
Records management systems generally distinguish between records and non-records (convenience copies, rough drafts, duplicates), which do not need formal management. Many systems, especially for electronic records, require documents to be formally declared as a record so they can be managed. Once declared, a record cannot be changed and can ...
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
A printed, optical, or electronic document designed to record all of the protocol-required information to be reported to the sponsor on each trial subject. (ICH E6) Case series A group or series of case reports involving patients who were given similar treatment. Reports of case series usually contain detailed information about the individual ...
Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties.
A machine-readable document is a document whose content can be readily processed by computers.Such documents are distinguished from more general machine-readable data by virtue of having further structure to provide the necessary context to support the business processes for which they are created.
Of the 84 awards given at the Grammys, the top three seem similar: Song of the Year, Album of the Year, and Record of the Year. Here's the difference.
Record to report or R2R is a Finance and Accounting (F&A) management process which involves collecting, processing and delivering relevant, timely and accurate information used for providing strategic, financial and operational feedback to understand how a business is performing. [1]