1. To select information from a patient’s medical record using hard copy or electronic equipment for statistical purposes or to submit an insurance claim for reimbursement.

2. At the end of a patient’s hospital stay, the attending physician prepares a report that summarises the diagnosis, treatment, and results and outlines any further treatment after discharge. This is referred to as a discharge summary.

See Also: Case Summary Card.

Individual who electronically or manually selects and extracts information from a patient’s medical record from computer files or paper files. Coded diagnoses can be used in a facility to track morbidity and mortality, infectious disease, and index disease information for quality of care and utilisation review. Another use for extracted data is the submission of insurance claims.