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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.
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.
The initial content of the database was to include the following: Drugs which the patient has been prescribed [6]; Known adverse reactions to drugs; Known allergies; In his announcement on 10 October 2010, the Health Secretary implied that its scope would in future be restricted to these three items, stating but that it would 'hold only the essential medical information needed in an emergency ...
A personal health record (PHR) is a health record where health data and other information related to the care of a patient is maintained by the patient. [1] This stands in contrast to the more widely used electronic medical record, which is operated by institutions (such as hospitals) and contains data entered by clinicians (such as billing data) to support insurance claims.
Providing patients with information is central to patient-centered health care and this has been shown to have some positive effects on health outcomes. [22] Providing patients with access to their health records including medical histories and test results via an electronic health record is a legal right in some parts of the world. [22]
It provides information for the continuation of care following discharge. [10] History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. [11] Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure.