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Electronic Health Records | CMS

    https://www.cms.gov/Medicare/E-Health/EHealthRecords
    An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, …

Summary of the HIPAA Security Rule | HHS.gov

    https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html
    Today, providers are using clinical applications such as computerized physician order entry (CPOE) systems, electronic health records (EHR), and radiology, pharmacy, and …

Electronic Health Record Systems - HHS.gov

    https://www.hhs.gov/sites/default/files/electronic-health-record-systems.pdf
    Consisted of three stages: Stage 1:establishes requirements for the electronic capture of clinical data, including providing patients with electronic copies of health information. …

HIPAA Guidelines for Electronic Medical Records - VRC

    https://vitalrecordscontrol.com/resources/health-information-management/hipaa-guidelines-electronic-medical-records/
    6) Destroy Medical Records – Properly. Dispose of PHI information by securely shredding electronic medical records according to destruction guidelines to …

Use of Electronic Health Record Data in Clinical …

    https://www.fda.gov/regulatory-information/search-fda-guidance-documents/use-electronic-health-record-data-clinical-investigations-guidance-industry
    This guidance is intended to assist sponsors, clinical investigators, contract research organizations, institutional review boards (IRBs), and other interested parties on …

EHR Implementation Communication Guidelines

    https://www.healthit.gov/resource/ehr-implementation-communication-guidelines
    EHR Implementation Communication Guidelines. The Electronic Health Record (HER) Communication guidelines are intended to aid providers and health IT implementers with …

Improved Patient Care Using EHRs | HealthIT.gov

    https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/improved-patient-care-using-ehrs
    Electronic health records (EHRs) can improve health care quality. EHRs can also make health care more convenient for providers and patients. Snapshot of …

Integrity of the Healthcare Record: Best Practices for …

    https://library.ahima.org/PB/EHRDocumentation
    There are a number of existing rules and regulations on documentation principles and guidelines that primarily address documentation authorship principles, auditing, and …

Guidelines for Medical Record Documentation

    https://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
    1. Each page in the record contains the patient’s name or ID number. 2. Personal biographical data include the address, employer, home and work telephone numbers …

Documentation Matters Toolkit | CMS

    https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation
    Documentation Matters Toolkit Providers are responsible for documenting each patient encounter completely, accurately, and on time. Because providers rely on documentation to communicate important …



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