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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 ...
Operative report. An Operative report is a report written in a patient's medical record to document the details of a surgery. [ 1] The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after ...
A certified copy is a copy (often a photocopy) of a primary document that has on it an endorsement or certificate that it is a true copy of the primary document. It does not certify that the primary document is genuine, only that it is a true copy of the primary document. A certified copy is often used in English-speaking common law countries ...
The National Personnel Records Center is the government agency tasked with replacing lost and destroyed DD Form 214s upon request from a veteran. Requested copies are mailed from the Military Personnel Records Center. Most veterans who separated from their service generally pre-1992 can obtain their DD 214 from the National Personnel Records ...
A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [ 1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient. All data on each patient participating in a clinical trial are held and/or documented in the CRF ...
Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records.The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements to doctors who fail to use ...
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