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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]
The patient, too, is entitled to the report, and other medical records, by the laws of most American states, and many other jurisdictions. Operative report standards are set by the Accreditation Association for Ambulatory Health Care (AAAHC) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
There are many forms of PHI, with the most common being physical storage in the form of paper-based personal health records (PHR). Other types of PHI include electronic health records, wearable technology, and mobile applications. In recent years, there has been a growing number of concerns regarding the safety and privacy of PHI.
The history of medical privacy traces back to the Hippocratic Oath, which mandates the secrecy of information obtained while helping a patient. Before the technological boom, medical institutions relied on the paper medium to file individual medical data. Nowadays, more and more information is stored within electronic databases. Research ...
Individuals have the broad right to access their health-related information, including medical records, notes, images, lab results, and insurance and billing information. [47] Explicitly excluded are the private psychotherapy notes of a provider, and information gathered by a provider to defend against a lawsuit. [48]
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare. Such documents have been in use for thousands of years during the entire history of ...
Schlagenhauf v. Holder, 379 U.S. 104 (1964), was a United States Supreme Court case in which the Court held that Rule 35 of the Federal Rules of Civil Procedure allows courts to order a defendant to submit to a medical examination.