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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 ...
C-CDA® Release 2.1. The HL7 Consolidated Clinical Document Architecture (C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1][2][3] All certified Electronic health records in the United States ...
Clinical Document Architecture. The HL7 Clinical Document Architecture (CDA) is an XML -based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0. The organization published Release 2.0 with its "2005 Normative Edition". [1]
The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [6][7] In contrast, a ...
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 ...
Medication Administration Record. A Medication Administration Record[1] (MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...