A specialist who pulls the key clinical data out of patient records so it can be analysed.
What they do
- Review patient records and abstract medical histories, diagnoses, procedures and medications
- Check that every abstraction is accurate and complete
- Read the data for trends and patterns, and report what they find
- Keep documentation current alongside the rest of the care team
Software
Electronic medical recordsClinical documentation software
Works with
The healthcare team, under HIPAA and current healthcare standards.
