"The systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction."
The documentation of a patient's medical history, diagnoses, treatments, and outcomes.
Anatomy and Physiology: Study of the structure and function of the human body systems, organs, and tissues. This is important for understanding the diagnostic and treatment methods used in healthcare.
Pathology: Study of disease processes and their effects on the body. This is important for understanding how diseases are diagnosed and treated.
Medical Terminology: Language used by healthcare professionals to describe medical procedures, diagnoses, treatments, and conditions.
Pharmacology: Study of drugs, including their action, uses, and side effects. This is important for understanding how medications are prescribed and administered.
Medical Ethics: Rules and principles governing medical practice and decision-making, including confidentiality, informed consent, and patient rights.
Medical Coding: Process of assigning codes to describe medical services and procedures for billing and insurance purposes.
Electronic Health Records (EHR): Digital records of patient information used to manage patient care, including medical history, diagnoses, treatments, and test results.
Health Information Management: Collection, analysis, and dissemination of information related to patient care, including medical records, billing, and quality metrics.
Health Insurance Portability and Accountability Act (HIPAA): Federal law regulating the use and disclosure of patient health information.
Medical Billing and Reimbursement: Process of submitting and tracking insurance claims and other charges for medical services. This includes understanding insurance policies and guidelines for billing and reimbursement.
Electronic Health Records (EHRs): This type of medical record contains the digital version of all the patient's medical history, including diagnoses, test results, and treatment plans.
Paper Records: This traditional type of record is a physical paper document containing notes, lab results, and other clinical documentation.
DICOM Files: DICOM stands for Digital Imaging and Communications in Medicine. These records refer to images from medical scans like X-rays, MRIs, and CT scans, which are stored electronically as DICOM files.
Personal Health Records (PHRs): These records contain the patient's relevant medical information, such as medical history, test results, allergies, and more, in a portable format.
Administrative Records: These records contain information about the patients' demographics, billing information, and insurance records.
Laboratory Reports: These records contain documentation of laboratory test results like blood tests, urine tests, and more.
Medication Records: These records contain documentation of the patient's medications and their dosage instructions.
Genetic Information Records: These records contain information about the patient's genetics and inherited diseases.
Progress Notes: These records contain documentation of the patient's progress and any changes in the treatment plan.
Radiology Reports: This type of medical record contains the interpretation of the diagnostic images by radiologists.
Pathology Reports: These records document results of the examination of tissue samples, biopsy, and other pathology tests.
Vital Signs Records: These records contain documentation of the patient's vital signs such as blood pressure, pulse, and temperature.
Rehabilitation Records: These documents contain information about physical therapy, occupational therapy, and other forms of rehabilitation prescribed to the patient.
Immunization Records: These documentations contain a history of the patient's vaccination records.
Consultation Records: These records contain written recommendations or opinions from medical professionals, specialists, and other clinical team members.
Discharge Summary: This record is created when a patient is discharged from a hospital or another medical facility. It summarizes their stay, diagnosis, treatments, and discharge instructions.
Operative Reports: These records contain information about the surgical procedures performed by a physician, including the details of the surgical procedure and its outcome.
Consent Forms: These records document the patient's agreement that legalizes their treatment or procedure involved during hospitalization.
Audio/Video Recordings: These records may refer to the recordings of the patient's medical procedures, surgeries, consultations, or other clinical sessions.
Audit Trails: These records document every action taken on the patient's medical record to ensure that unauthorized access is prevented.
"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 care providers."
"The maintenance of complete and accurate medical records is generally enforced as a licensing or certification prerequisite."
"Advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites."
"This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association."
"Many consider the information in medical records to be sensitive private information covered by expectations of privacy."
"Many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal."
"The storage equipment for medical records generally is the property of the health care provider."
"The actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request." Note: Due to the complexity of the passage, it might be difficult to find immediate quotes that precisely answer each question in a concise manner. However, the quotes provided generally address the main points and concepts in relation to the study questions.