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Medical transcriptionists work with healthcare providers to make sure that each visit is documented so that there is a complete record of the diagnosis and treatment plan as well as any follow-up ...
Medical transcription editing is the process of listening to a voice-recorded file and comparing that to the transcribed report of that audio file, correcting errors as needed. Although speech recognition technology has become better at understanding human language, editing is still needed to ensure better accuracy.
Abbreviations are used very frequently in medicine. They boost efficiency as long as they are used intelligently. The advantages of brevity should be weighed against the possibilities of obfuscation (making the communication harder for others to understand) and ambiguity (having more than one possible interpretation).
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 ...
Clinical Coder. A clinical coder —also known as clinical coding officer, diagnostic coder, medical coder, or nosologist —is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system. The health data produced are an integral part of health information ...
This is a list of abbreviations used in medical prescriptions, including hospital orders (the patient-directed part of which is referred to as sig codes). This list does not include abbreviations for pharmaceuticals or drug name suffixes such as CD, CR, ER, XT (See Time release technology § List of abbreviations for those).