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Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
In computing, an enterprise[-wide] master patient index is a form of customer data integration (CDI) specific to the healthcare industry.Healthcare organizations and groups use EMPI to identify, match, merge, de-duplicate, and cleanse patient records to create a master index that may be used to obtain a complete and single view of a patient.
Vital records are records of life events kept under governmental authority, including birth certificates, marriage licenses (or marriage certificates), separation agreements, divorce certificates or divorce party and death certificates. In some jurisdictions, vital records may also include records of civil unions or domestic partnerships.
For example, sharing information about someone on the street with an obvious medical condition such as an amputation is not restricted by U.S. law. However, obtaining information about the amputation exclusively from a protected source, such as from an electronic medical record, would breach HIPAA regulations. Business Associates
In medicine, a social history (abbreviated "SocHx") [1] is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.
Records management, also known as records and information management, is an organizational function devoted to the management of information in an organization throughout its life cycle, from the time of creation or receipt to its eventual disposition.
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