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The adoption of electronic medical records refers to the recent shift from paper-based medical records to electronic health records (EHRs) in hospitals. The move to electronic medical records is becoming increasingly prevalent in health care delivery systems in the United States , with more than 80% of hospitals adopting some form of EHR system ...
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive ...
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
Hard copy replacement: PACS replaces hard-copy based means of managing medical images, such as film archives. With the decreasing price of digital storage, PACS provide a growing cost and space advantage over film archives in addition to the instant access to prior images at the same institution. Digital copies are referred to as Soft-copy.
It is released under the MIT license, but compatible medical devices are proprietary. [59] Ushahidi allows people to submit crisis information through text messaging using a mobile phone, email or web form. Displays information in map view.
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...