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medical record (1)
(definition number 1) is a folder that is filed at the healthcare facility where treatment is given. It is retrieved, updated, and expanded as the patient’s care progresses. The problem with calling this folder the medical record is that invariably a patient will have a folder at each physician’s office and facility in which he seeks care. So the medical record is essentially a bunch of medical records.
medical record (2)
(definition number 2) is the collective sum of information pertaining to the history of a patient’s care. This often does not really exist because, as we mentioned earlier, the individual records are scattered. There has been some success with electronic health records being consolidated and stored centrally, with easy access for all facilities, and we will discuss the electronic health record in depth later in this module.
responsibility of the MTE
To edit, organize and verify the individual reports that are stored in the medical folder and become a permanent part of the patient’s medical folder.
electronic health records (EHR)
a digital form of a person’s collective medical record. It relies on computer software and hardware to gather, organize, store, and retrieve it. The EHR will, like a paper folder, house medical reports, lab tests, images, x-rays, and payment information. The EHR certainly has many advantages.
The EHR is:
Centralized – Making it easily accessed remotely
Organized – All data in one place
Searchable – Finding specific data almost instantly
Efficient – Less time adding, writing by hand, faxing
Comprehensive – Covering all encounters from many sources
Easily Audited – Either manually or electronically
Fully Integrated – Allowing various medical decision-makers access to pertinent data
Accurate – Purported to reduce medical errors
speech recognition technology (SRT)
takes human speech and changes it into data that a computer can recognize. This complex, yet seemingly simple operation of digitally translating the human voice into text is creating an array of new uses for speech recognition technology in many different industries and uses in daily life.