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Continuity of Care Record (CCR) [1] is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors.
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.
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.
Interoperability between disparate clinical information systems requires common data standards or mapping of every transaction. However common data standards alone will not provide interoperability, and the other requirements are identified in "How Standards will Support Interoperability" from the Faculty of Clinical Informatics [2] and "Interoperability is more than technology: The role of ...
Medical standards of care exist for many conditions, including diabetes, [3] some cancers, [4] and sexual abuse. [5] Failure to provide patients treatment that meets a standard of care can incur legal liability for any injury or death that results. In large-scale disasters, public authorities may declare crisis standards of care apply. This ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Manifest Your Goals. Taking time on New Year's Eve to truly meditate and reflect on the year ahead is an excellent way to head into the new year with a focused, clear mindset.Try breaking your ...
The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards. [citation needed] CCDs are quickly becoming one of the most ubiquitous and thorough means of transferring health data on patients as each can contain vast amounts of data based on the standard format, in a relatively easy to use and portable ...