Health Information Technology As An Allied Health Profession

1510 Words Nov 15th, 2015 7 Pages
Health information technology was officially recognized as an allied health profession in 1928. Prior to that, in 1918, the Hospital Standardization Movement, led by the American College of Surgeons, implemented the requirements for a patient’s medical record. Believing that complete information was necessary and important to a patient’s care, the movement required certain items to be included. Any record created must contain the patient’s complaint, along with personal and family history and the history of the present illness. This includes the onset and symptoms. A provider must document that he/she performed a physical exam on the patient and ensure that any clinical studies like laboratory and x-ray results are included. Any past history, such as medical or surgical treatment must be included as well. Finally, progress notes, working or final diagnosis and any recommended follow up must be documented. Should death occur while the doctor is treating the patient in the hospital, autopsy findings, if performed, must be entered (Sayles, 2013).
Before this movement, the creation and maintenance of a patient’s medical record was the attending doctor’s responsibility (Sayles, 2013). When a patient was hospitalized, there was no official medical records department to ensure that the chart was complete. The records typically only contained information written down by the doctor, no laboratory or radiology reports (Sayles, 2013).
Since 1918, health care has evolved…
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