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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.
The key advantage of providing information from the physician in charge of treatment for a single patient to the different roles involved in processing he treatise itself is widely innovative. This makes CPOE the primary tool for information transfer to the performing staff and lesser the tool for collecting action items for the accounting staff.
On the other side, some patient check in systems are simple, fast and more cost effective. Instead of trying to replace the office staff, simple systems complement the existing EMR and give the staff a tool for organizing the patients. Simple systems generally only collect the name, reason for visit and a timestamp.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
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.
Some patient portal applications enable patients to register and complete forms online, which can streamline visits to clinics and hospitals. Many portal applications also enable patients to request prescription refills online, order eyeglasses and contact lenses , access medical records , pay bills, review lab results, and schedule medical ...
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Case report forms contain data obtained during the patient's participation in the clinical trial. Before being sent to the sponsor, this data is usually de-identified (not traceable to the patient) by removing the patient's name, medical record number, etc., and giving the patient a unique study number.