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The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for ...
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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]
For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the International Classification of Diseases (ICD), the Healthcare Common procedural Coding System (HCPCS), and Current Procedural Terminology (CPT) for reporting to the health insurance provider of the recipient of the care.
This can be described as the time frame at which one completes certain tasks or duties. For example: a technician will be given blood cultures (a lab specimen collected to verify the growth of bacterium in the blood system. [11]), routine lab collections, glucose testing, [12] and equipment processing (cleaning of medical equipment). Depending ...
Take for example electronic health records (EHRs) and their widespread use in the field today. Ever since the implementation of these electronic databases, EHRs have made it easier for physicians and medical professionals to gain access to the patient's records, and have made managing and storing the records safely. [17]