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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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [12] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed. [1] This bill is called a claim. [2]
The Blue Button Logo, April 2012. The Blue Button is a system for patients to view online and download their own personal health records.Several Federal agencies, including the Departments of Defense, Health and Human Services, and Veterans Affairs, implemented this capability for their beneficiaries. [1]
The rate dropped to 6.69% from 6.81% last week, mortgage buyer Freddie Mac said Thursday. Borrowing costs on 15-year fixed-rate mortgages, popular with homeowners seeking to refinance their home ...
Every medical treatment facility should have policies and processes on equipment control and asset management. Equipment control and asset management involves the management of medical devices within a facility and may be supported by automated information systems (e.g., enterprise resource planning (ERP) systems are often found in U.S. hospitals, and the U.S. military health system uses an ...
Chopra says Rodgers was immediately “really trusting” with him and Hughes, adding that throughout their year working together on the documentary, Rodgers “was very open and vulnerable.”