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A medical record includes 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 ...
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 ...
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 ...
Health information management (HIM) is information management applied to health and health care. It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with ...
A patient portal is a secure website set up by a health care system, hospital, or clinic. The tools (or features) vary, depending on the portal. Patient portals can help you access medical records ...
Step 2: Check your doctor's website. If you visit a medical practice, your doctor may have details on how to request your medical record on their website. Step 3: Call or e-mail your doctor ...
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