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Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...
In computing, an enterprise[-wide] master patient index is a form of customer data integration (CDI) specific to the healthcare industry.Healthcare organizations and groups use EMPI to identify, match, merge, de-duplicate, and cleanse patient records to create a master index that may be used to obtain a complete and single view of a patient.
Audit trails refer to keeping information about who had recently used or accessed patient records. Through the usage of audit trails and the above-mentioned security steps, Electronic Health Records could most probably be made the best way of collecting, storing, retaining and using patient health information. [citation needed]
Patient check-in is the process where patients begin their registration with the healthcare facility topically using a clipboard, electronic tablet, touch screen, kiosk, or by other method, sometimes self-service. Patient check-in start as far back as the Roman times when patients would wait for special services in purpose-built hospitals.
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. [1] These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges.
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]
Information also frequently collected and found in medical records includes, administrative and billing data, patient demographic information, progress notes, vital signs, medications diagnoses, immunization dates, allergies, and lab results. [6] Recent advances in health information technology have expanded the scope of health data.
The privacy of patient information is protected at both the federal level and provincial level in Canada. The health information legislation established the rules that must be followed for the collection, use, disclosure and protection of health information by healthcare workers known as "custodians". These custodians have been defined to ...