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A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information ...
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.
Medical audit later evolved into clinical audit and a revised definition was announced by the NHS Executive: "Clinical audit is the systematic analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for the patient."
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Epic was founded in 1979 by Judith R. Faulkner [5] with a $70,000 investment [6] (equivalent to $300,000 in 2024). Originally headquartered in Madison, Wisconsin, Epic moved its headquarters to a large campus in the suburb of Verona, Wisconsin in 2005, [7] where it employs 13,000 people as of 2023. [8]
A chart recorder which is part of a polygraph A circular chart recorder. A chart recorder is an electromechanical device that records an electrical or mechanical input trend onto a piece of paper (the chart). Chart recorders may record several inputs using different color pens and may record onto strip charts or circular charts.
The terms EHR, electronic patient record (EPR), and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. [6] The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations.
The first documented description of a peer review process is found in the Ethics of the Physician written by Ishap bin Ali al-Rahawi (854–931) of al-Raha, Syria. His work, as well as later Arabic medical manuals, states that a visiting physician must always make duplicate notes of a patient's condition on every visit.