Zusammenfassung
The patient chart, or medical record, is the permanent documentation of the care and treatment given to a patient during one or more visits to the hospital. Beyond its use as a place to record and reference on-going activity while a patient is in the hospital, the medical record is an important source of data in other areas: medical, legal, financial and educational. It is important that the data in the medical record be accurate, complete, timely and readable. It is also important that, as much as possible, information be presented in a structured and uniform manner to facilitate extraction and comparison of data.
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© 1986 Springer-Verlag Berlin Heidelberg
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Clayburn, A. (1986). Medical Records Coding and Analysis with IBM’s Patient Care System. In: Ehlers, C.T., Beland, H. (eds) Perspektiven der Informationsverarbeitung in der Medizin Kritische Synopse der Nutzung der Informatik in der Medizin. Medizinische Informatik und Statistik, vol 64. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-82852-2_65
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DOI: https://doi.org/10.1007/978-3-642-82852-2_65
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-540-16825-6
Online ISBN: 978-3-642-82852-2
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