HSCI 3500 Study Guide - Quiz Guide: Electronic Health Record, Health Informatics, Ehealth Exchange

• School: Saint Louis University
• Department: Health Sciences
• Course: HSCI 3500
• Professor: Wolter

Document Summary

Medical record: a (cid:272)o(cid:373)pilatio(cid:374) of (cid:396)ele(cid:448)a(cid:374)t fa(cid:272)ts of a patie(cid:374)t"s life a(cid:374)d health, histo(cid:396)(cid:455), What is a medical record? including past and present illnesses and treatments written by the people contributing to that patie(cid:374)t"s (cid:272)a(cid:396)e. 5 roles: represents that patie(cid:374)t"s health histo(cid:396)(cid:455, provides clinical communication, serves as legal document, source of data for clinical, health service, and research, serves as major resource for healthcare education. It must: be compiled in a timely manner, contain sufficient data to identify the patient, support the diagnosis or reason for healthcare encounter, justify the treatment, accurately document results. The medical record is owned by the institution where it was developed, while the information contained in the record is owned by the patient. Some uses of medical record include: patient care, financial reimbursement, legal affairs, education, planning and marketing, quality review, research, and public health.