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The Medical Transcriptionist’s
Role With The Healthcare record Submitted
By: Connie Limon The healthcare record is:•Chronological•Documents
of a patient’s initial database •Initial
evaluation•Identified problems and
needs•Objectives of care•Prescribed
treatment•Results The healthcare record
belongs to the hospital, medical facility
or office where it originated. It cannot
be removed from the premises without a subpoena
or court order.
Although much of the healthcare record is
maintained through computer software systems,
most medical care facilities still maintain
a “paper” healthcare record
of some sort.The healthcare record is maintained
by the Health information Department of
hospitals and medical facilities and usually
headed by a registered record administrator
or an accredited record technician.A former
term for the healthcare record for over
fifty years was
“Medical Record.” The new term
of healthcare record denotes both illness
and wellness. The Medical Record Department
name has also changed to Health Information
Department.What is the purpose of a healthcare
record?It is a measurement and documentation
of care rendered in a medical facility.
The healthcare record is used to plan, communicate
and evaluate the quality of care given to
each patient. It provides “proof”
of work done for each patient. Documents
are required to meet federal, state, and
JCAHO (Joint Click
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