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Hospital emergency codes are coded messages often announced over a public address system of a hospital to alert staff to various classes of on-site emergencies. The use of codes is intended to convey essential information quickly and with minimal misunderstanding to staff while preventing stress and panic among visitors to the hospital.
The terms EHR, electronic patient record (EPR) and EMR have often been used interchangeably, but differences between the models are now being defined. The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record ...
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 ...
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 ...
Operative report. An Operative report is a report written in a patient's medical record to document the details of a surgery. [1] 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 ...
Medical billing is a payment practice within the United States healthcare system. The process involves the systematic submission and processing of healthcare claims for reimbursement. Once the services are provided, the healthcare provider creates a detailed record of the patient's visit, including the diagnoses, procedures performed, and any ...
Computerized physician order entry. Computerized physician order entry ( CPOE ), sometimes referred to as computerized provider order entry or computerized provider order management ( CPOM ), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her ...
In healthcare, a change-of-shift report is a meeting between healthcare providers at the change of shift in which vital information about and responsibility for the patient is provided from the off-going provider to the on-coming provider (Groves, Manges, Scott-Cawiezell, 2016). [1] Other names for change-of-shift report include handoff, shift ...