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The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation ...
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]
An individual who performs medical transcription is known as a medical transcriber (MT) or a Medical Language Specialist (MLS). The equipment used is called a medical transcriber, e.g., a cassette player with foot controls operated by the MT for report playback and transcription.
Emergency medical services: EMT: Emergency medical technician: EMT-B: Emergency Medical Technician - Basic(OLD) EMT-I: Emergency Medical Technician - Intermediate (OLD) EMT-P: Emergency Medical Technician - Paramedic (OLD) EN: Enrolled nurse (AU) – See Licensed practical nurse: EORTC: European Organization for Research Treatment in Cancer EpSSG
Scribes also find information (such as medical records from other hospitals or test results) and people (such as on-call consultants). Medical scribes can be thought of as data care managers and clerical personal assistants, enabling physicians, medical assistants, and nurses to focus on patient in-take and care during clinic hours.
One of the federal laws enacted to safeguard patient's health information (medical record, billing information, treatment plan, etc.) and to guarantee patient's privacy is the Health Insurance Portability and Accountability Act of 1996 or HIPAA. [109] HIPAA gives patients the autonomy and control over their own health records. [109]