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A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
In computing, an enterprise [-wide] master patient index is a form of customer data integration (CDI) specific to the healthcare industry. Healthcare organizations and groups use EMPI to identify, match, merge, de-duplicate, and cleanse patient records to create a master index that may be used to obtain a complete and single view of a patient ...
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [13] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
Health information management ( HIM) is information management applied to health and health care. It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with ...
PubMed. PubMed is a free database including primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics. The United States National Library of Medicine (NLM) at the National Institutes of Health maintains the database as part of the Entrez system of information retrieval.
Records management, also known as records and information management, is an organizational function devoted to the management of information in an organization throughout its life cycle, from the time of creation or receipt to its eventual disposition. This includes identifying, classifying, storing, securing, retrieving, tracking and ...
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.
For example, for diabetes, HEDIS selects an eligible population based on age (18–75 years), continuous enrollment with a certain health insurer and certain "Events/diagnosis" from pharmacy data (electronic), insurance claims data (electronic) or from medical records. Pharmacy data is based on a list of medications prescribed for diabetes.