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Ambulatory Electronic Health Record Abstraction


Job Summary

    Abstraction Overview Abstracting is the process of entering the Ambulatory Electronic Health Record (AEHR) with discrete clinical data from the historical patient paper medical record. Abstraction Procedures: The following data are the items abstracted and entered into the AEHR: 1. Allergies 2. Current Medications 3. Active Problems 4. Past Medical History 5. Past Surgical History 6. Family History 7. Social History 8. Immunizations 9. Advance Directives 10. Most Recent Height and Weight (Pediatrics Only) • Care should be taken to review the clinical data already in the paper record as to avoid duplication or conflicting clinical data. • In the event that discrepancies are identified between the paper record and existing information already entered in the AEHR, the following steps should be taken: a. The record will be flagged for review by offshore doctor in India. b. A notation will be made of the exact nature of the discrepancy in the “Discrepancies/Comment” column of the Abstraction Reconciliation and Attestation form c. The offshore doctor will review the discrepant information and notify the on-site provider(s) d. The on-site provider(s) will review the discrepant information with the patient during the next face-to-face visit and modify the electronic medical record if appropriate


  • Location: Gurgaon
  • Job Title: Ambulatory Electronic Health Record Abstraction
  • Designation: Abstraction process
  • Salary: 2 LPA - 5 LPA
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