a medical record is an example of:a medical record is an example of:

Here are a few examples of medical errors: Having surgery performed on the incorrect part of the body. Coming to the end of therapy treatment can be a daunting prospect for many clients. Test your vocabulary with our 10-question quiz! Additionally, as Medical Record Summaries are often required by third-party organizations such as insurance companies or law firms, you should take extra care to ensure you are authorized by the patient to share this Medical Record Summary. Plus, Jotform is HIPAA-compliant and that is gigantic in addition to for anybody in the medicinal services industry. Some of these professionals may include. Enables the patient to perform activities of daily living and to achieve as much independence as. BMI Chart document useful for both individuals and dietitians to track and document their records. A patients medical history may include details about past diseases, illnesses running in the family, previous diagnoses, medical abstract, therapies, allergies, and medication. "Medical reimbursement is reflective of what you document, not just what you do," says Dr. David Schillinger, SCP Health's Chief Medical Officer. As a Medical Record Summary may often be used in legal cases, it is crucial these details are accurate so take extra care in filling them in. Non curabitur gravida arcu ac tortor dignissim convallis aenean et. Here is a useful worksheet designed to help clients recognize, manage, and ultimately overcome their negative thoughts. May be the patient's regular physician or a different physician. 'Hiemal,' 'brumation,' & other rare wintry words. Your email address will not be published. A medical record is considered private because it includes identifiable information that has been provided for specific purposes by an individual and that the individual can reasonably expect will not be made public. record of the significant information obtained during an emergency department visits. Others use online forms while some also use PDF forms. A comprehensive therapy worksheet template that improves patient engagement. What is the information of medical record used for? Its a very important part of their workflow to ensure theyre providing the best care and treatment. Thanks to this medical history record sample, the doctor knows about patients medical history. Your email address will not be published. Likewise, accessing medical records, or even demographics of family members, friends, co-workers, a celebrity, politician or any other public figure is snooping, if it's done for a reason . The terms medical Report must be completed and signed by the attending physician. Learn how to practice mindfulness today. C. use of box design Elevate confidence, self-esteem, and target desired outcomes with this useful resource. LNCs are qualified nurses who act as a bridge between the healthcare and legal fields, particularly in cases of medical malpractice where expert knowledge and medical experience are needed., Thats not to say that others cannot utilize this template in summarizing medical records, but it is crucial that the person completing this record has a medical background or knowledge of medical terminology and short-hand so they can accurately condense down key points from the medical record into the summary. Ensure you handle the end of their sessions with care using our therapy termination worksheet. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to. An EMR (electronic medical record) is a digital version of a chart with patient information stored in a computer and an EHR (electronic health record) is a digital record of health information. The medical record refers to the ; Aggregated medical record: This type of record is a database that includes lots of different data called attributes.This type of record is not used to identify one person. One of the best benefits of this Medical Record Summary template is that it can be completed entirely digitally. Properly documenting patient's medical records has always been important, but never more than now, given today's healthcare landscape where the government ties reimbursement to the quality of the medical record. We know that some of you have been using the app for a very long time, and many of you were already sick before you came to us. Improve speech and language therapy outcomes with our free worksheets. 116 363 dyads (from 80 442 families) had complete data (including parent BMI, child BMI, child gender, race, insurance status, age, and Charlson Comorbidity Index) and were included in our . With blank page numbering on the second page provided, you can simply print out as many copies of the second page as you need and add in the page numbers when youre done. Implement our therapy worksheet for teens, and help your adolescent patients achieve their goals. Why Use Carepatron For Medical Record Summaries? These cases can be time-consuming and expensive, and will undoubtedly require a lot of paperwork. 3 Every entry in the health record should be authenticated and traceable to the author of the entry. Designed to adapt to various therapeutic purposes, you can ensure higher engagement and more meaningful connections between participants. Collect important information about food restrictions and allergies. refers to the scientific method of determining and identifying a patients condition. A medical record is an example of: Answer: Private information. If you want to collect the medical history information and record these data as a pdf, Jotform will help you! [C] Why Is This Template Useful For Health Professionals, Benefits Of Using The Medical Record Summary Template. Or, you can jump straight into your own Medical Record Summaries and download the blank PDF Medical Record Summary template right here. Easy to customize, download, and print. An EMR is an electronic medical record and an EHR is an electronic health record. We reviewed their content and use your feedback to keep the quality high. Explore our therapy worksheets for kids to support emotional and mental well-being. Here are the key facts about medical records technician resumes to help you get the job: The average medical records technician resume is 421 words long Step 4: Send your request Depending on your provider's processes, you may be able to deliver your request different ways: Secure email through your patient portal Non-secure email (your personal email) Fax Such purposes typically include the provision of adequate and appropriate medical care requested by the patient or deemed necessary for the patient based on the record's contents. An EMR is usually a record within a single provider's office. This template contains all the information required in conducting research and report. This concept is supported by AHIMA, US Private information. 2023. The medical record excludes health records that are not official business records of UC, He's worked as both an freelancer and with Business Today before joining our team, but his addiction to self help books isn't something you can put into words - it just shows how much time he spends thinking about what kindles your soul! Have you had the Hepatitis B vaccination? Public information A health care provider or health plan may send copies of your records to another provider or health plan only as needed for treatment or payment or with your permission. There should be a clear notation how you have derived the specimens. When correcting or making a change to an entry in a computerized medical record system, the original entry should be viewable, the current date and time should be entered, the person making the change should be identified, and the reason should be noted. Access our treatment plan for depression to alleviate patient depressive symptoms and work towards achieving greater psychological well-being. Encourage greater mindfulness, acceptance, self-awareness, and understanding. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form. What does a medical office clinical document include? Also, the patient will need a consent an Electrocardgram(ECG) report is a narrative description of a cardiologists interpretation of an ECG, including implications for the patient. Not a problem! narrative description of the interpretation of a sigmoidoscopic examination including the practitioners impressions. provisional diagnosis and tentative diagnosis. Medical History Record PDF template is mostly used in order to provide significant information about the health history, care requirements, and risk factors of the patient to doctors. Help your patients struggling with substance abuse put their best foot forward on the road to recovery with our Treatment Plan for Substance Abuse template. Provide the best health care to the people by using evidence-based care study by using this Medical Case Report template. To be precise, the components of a medical record include a patient's health status, social status, occupational history, financial status, and so on. These templates are suggested forms only. Its not a very realistic experience when it is your brain that is not able to tell you something is wrong. Cognitive-Behavioral Therapy (CBT) is a type of psychotherapy seeking to identify and modify unhelpful or distorted thinking patterns. In an emergency, you might not be able to effectively communicate about your full medical history with the paramedics. It also Pulls charts for telephone messages and delivers to physicians, phone nurse and medical assistants. Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1 (described in the plan below). Check out our stages of change worksheets to help clients recognize the six change dimensions. detailed information related to a patients medications. A medical record is a self-awareness because you are aware of the problem. So, aside from these PDF templates that were pre-built and designed for you, you also enjoy the advantages of using a platform thats HIPAA-compliant. Because you are aware that something is wrong, you can come up with a solution, and that is the solution. an exampleofPrivate information. Describes the surgical procedure and must be completed and signed by the surgeon who performed the operation. Luckily, your clients can start practicing gratitude with our Gratitude Worksheet, offering six different prompts to get them thinking about the people, places, and things they are grateful for in their daily lives. . You can use this the Medical History Record PDF template with HIPAA Compliant. report of the analysis or examination of body specimens. Not to worry, our Medical Record Summary Template is flexible enough to be used for Medical Summaries of any length. But the problem is that its a little bit like a disease, like a disease you get sick for, and you dont know that its a problem until you have it. Target your clients negative thought processes and help them find alternative and more effective thoughts with our ABCDE Worksheet based on the principles of Cognitive Behavioral Therapy. You'll get a detailed solution from a subject matter expert that helps you learn core concepts. systematic documentation of the private information of a patient. Increase accuracy in identifying and recognizing negative thought patterns by downloading our automatic negative thought worksheets. Stave off the relationship apocalypse by learning to recognize the four relationship horsemen and their antidotes, as posited by Dr. John Gottman, to prevent a relationship from ending in disaster. Thats the first problem with self-awareness. Indicate whether the following statements are true or false. Private behavior. All codes of unlisted procedures are divided according to the numerical position. Often, this summary would have been created in order to be shared with another provider or third party, and in this case, you should ensure it is shared securely, and that you have been authorized to disclose the patient health information contained in the Medical Record Summary. Smoothen the onboarding process, and ensure you dont miss any critical information. This is recorded by an attendant and the records of such must be kept for historical purposes.This Occupational First Aid Patient Assessment PDF template is your easy to use document for your company. This Self-Care Worksheet will help determine objectives in their physical, personal, spiritual, psychological, and professional domains. Who might an occupational therapist help? A flexible and practical Normal Physical Exam Template that improves your patients' examinations. It includes information about p. To gain access to they serve to document the patients health status from one visit to the next. Gathering your patients' medical information may be a troublesome task. Patients can fill out their information on a computer or tablet using our Dental Health Record Template. A medical record is an example of Private information. As such, the profession that may be best suited to this task is Legal Nurse Consultants (LNCs). What action can he expect by the IRB? A medical record is a patients full collection of progress notes, test results, encounters, appointment notes, and all other documentation relating to the patients medical history. Many physicians object to its use for various reasons - it is too . Start collecting physical fitness records of your participants for your boy scout activities with this Boy Scout Camp Physical Form. Challenge your clients anxious thoughts and create rational and helpful alternatives with our Anxiety Worksheet. View in PDF (Download) Similar Queries HIPAA Health Insurance Portability and Accountability Act of 1996 Nuremberg Code Answer: Human subjects research guidelines and regulations Depts. Medical records are an essential piece of documentation that follows us throughout our lives. This Veterinary Treatment Sheet template contains the necessary information for recording and tracking treatment process for your client's pet. Our CBT ABC worksheet is designed to help patients rationalize their thought patterns and improve self-talk. collection of supjective date about the patient, having the patient complete a pre printed form that is then recieved for completeness by the medical assistant. authorization of the patients waiver. record can be interchangeably used with a health record and a medical chart to Add your own branding, adjust fields for your specific needs and then simply print out your PDF for the patient's file. Gather rich insights on your client's daily nutrition intake using our Nutrition Chart, designed for Registered Dietitians and Registered Dietitian Nutritionists to help their clients achieve their personalized nutrition goals. patient registration record and the patient related correspondence. This includes orders and medical record documentation of all services provided. medical record noun : a record of a patient's medical information (as medical history, care or treatments received, test results, diagnoses, and medications taken) Dictionary Entries Near medical record medical psychology medical record medical transcriptionist See More Nearby Entries Cite this Entry Style "Medical record." Useful for gauging self-awareness, this template will lead to effective treatment plans. full name, address, telephone number (home,work,cell), date of birth, gender, marital status, employer. Moreover, you do not worry about your data security because our templates protected by HIPAA Compliance. Veterinary Hospital Treatment Sheet helps both the hospital and pet owners in understanding and tracking a pet's treatment process. Download our EMDR negative cognition list to support your EDMR practices in evaluating and treating clients with PTSD. involve updating the medical record with new information each time the patient visits or telephones the office. assesment of each part of the patients body, provide objective data about the patient, assist the physician in determining the patients state of health. narrative description of a colonoscopic examination including the practitioner's impressions. For example, they may say no to sharing information if they're not sure the person asking for the records has a right to see them. 2003-2023 Chegg Inc. All rights reserved. I knew this because I was a healthy child and I took an oral steroid. Increase daily functioning in patients, as well as healthy thoughts, feelings, and positive behaviors. It's also worth mentioning that this template is different from the first one because it includes a top-remit. Improve your relationships with Carepatrons free Healthy Relationships Worksheets. Or, you can jump straight into your own Medical Record Summaries and download the blank PDF Medical Record Summary template right here. Powerful therapy goals worksheet that helps your clients to achieve better therapy outcomes. brief(usually one page) summary of the significant events of a patients hospitalization. The last step is to sign and add your name to the first page, and store the document securely as it contains confidential patient health information. UQ will comply, and will use all reasonable endeavours to ensure that the Student and UQ Employees comply with clause 7.1 and, with the Provider's privacy code and all applicable laws which apply to Medical Records.. Subject to the Maryland Public Information Act and any other applicable laws including, without limitation, HIPAA, the HI-TECH ACT . Receiving the incorrect meal while in the hospital, such as a regular meal when you require a salt-free meal. (b) What is the molarity of the solution? Kids can struggle to cope with big feelings, but you can help them understand and problem-solve their emotions through alternative thoughts, phrases, and actions using our Feelings Worksheet for Kids. A practical and engaging substance abuse worksheet to help keep your patients involved with their care. A medical record is not considered public information, nor is it considered a behavior. required to bill charged to the patient or an insurance company, name of responsible party(person responsible for the account), social security number, address of responsible party, name of insured (policyholder), insurance company, policy number and group number, secondary insurance company. But theres more where that came from. These resources will aid clients in identifying and challenging underlying beliefs and promoting growth and well-being for a higher quality of life. Free to customize, download, share, and print. By incorporating our intuitive form within your acupuncture practice, save time with your intake processing. copies of letters concerning the patient that are send out of the office. What forms are used for medication records? I am a digital marketer, accountant and a passionate writer. Download or print as PDFs. The DRS may also include an expanded version of the documentationthe summary of findings and also images from the procedure. From medical history, laboratory test results, to diagnosis documentation, a single medical report can say a lot about a person's health. the accurate and complete medical record is the need of the health care providers. This Self Care Assessment Worksheet includes a variety of self-care activities for your client to rank, allowing them to highlight the specific areas they want to work to improve. "(a) Scarce and critical materials.During a public health emergency, any medical equipment or supplies determined by the Secretary of Health and Human Services or the Secretary of Homeland Security to be scarce and critical materials essential to the national defense for purposes of section 101 may be deemed by the President to be a scarce and critical material essential to the national . For progress notes, what is important to include? In a two-stroke internal combustion engine, the intake, compression, expansion, and exhaust operations are accomplished in two revolutions of crankshaft. Quis ipsum suspendisse ultrices gravida dictum fusce. What is the purpose of the discharge summary? The medical record is a fine collection of one's medical diagnoses and treatment details. Prevent allergic reactions and collect food allergy information online. Help your clients get in touch with their emotions and uncover how their feelings, thoughts, and behaviors are interconnected with our free PDF Emotions Worksheet. Take a look at our example Medical Record Summary template based on a fictional encounter with a dissatisfied patient taking legal action. narrative description of the interpretation of a 24 hr ambulatory ECG, including the evaluator's impressions. It describes or outlines the findings of a medical professional, along with any suggestions for the patient's treatment and recovery. It is for collecting data from the patients. Intuitively designed and easy to use, this template will enable clients to achieve desired outcomes. nurses, home health aides, dietitians, physical therapists, occupational therapists, speech therapists, and social workers. An Occupational First Aid Patient Assessment is a document that puts into record the injuries or signs or symptoms of diseases provided by the patient or his or her companion. national health administration entities, and by the American Health Information Enhance the quality of life for your patients, no matter their life changes, and simplify healthcare processes so you can spend more time doing what you love. \degreeC) if it takes 97.2 J to raise the temperature of a 75.0 g block by 10.0 \degreeC? It consists of the patients' clinical information and the medical history and also about the patient's progress and medication. Previous question Next question. Dont worry about fitting in all the information on the first page, you can make as many copies of the second page of the PDF as you need for your Medical Record Summary and number them once you are finished. used as a basis for decisions regarding the patients care and treatment. A Parts Work Therapy Worksheet that helps transform internal parts to resolve inner conflict. Feeling grateful for the good things in life is a hugely beneficial habit, but it takes practice to become routine. Answer six simple questions to reflect on a relationship and identify areas for growth. along with physical examination and laboratory and diagnostic tests, the health history is used to determine the patients general state of health, arrive at a diagnostic,to prescribe treatment, and document any change in a patients illness after treatment has been instituted. But if we have a medical record, we can find the person whos sick, and that would be the problem. Which of the following describes a growth mindset, as opposed to a fixed mindset. Help patients improve their coping skills with our anger management worksheet for teens. a patients medical records, the researcher needs to request consent and Our Solution-Focused Therapy Worksheet is designed to help patients articulate their issues and devise possible solutions. Experiencing negative thoughts can be a difficult experience for many individuals. Empower clients to step away and create effective action plans that promote higher respect, self-esteem, and self-awareness. Jotform Inc. Methods: We retrospectively analysed . ; urine, blood, throat, sputum, wound,urethral,vaginal,cerebrospinal), deals with the detection of disease-producing human parasites or eggs in specimens taken from the body. A medical information form template designed to improve data accuracy and enhance the quality of care. The purpose of authentication is to show authorship and assign responsibility for an act, event, condition, opinion, or diagnosis. Parturient montes nascetur ridiculus mus. This should be completed in chronological order, with the earliest entry at the top of the table. Who enters the information from the patient registration form? Help your clients overcome their struggles with substance abuse, addiction, or other behavior harming their well-being by developing your motivational interviewing skills using our Motivational Interviewing worksheet. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. Practice Fusion is a cloud-based EHR system that securely stores data on external servers and can be accessed with any device that has an internet . Template designed to adapt to various therapeutic purposes, you might not able. Act, event, condition, opinion, or diagnosis engine, the intake, compression,,. The onboarding process, and ultimately overcome their negative thoughts can be a daunting prospect many! Mindset, as well as healthy thoughts, feelings, and print full medical history with the paramedics in emergency... For depression to alleviate patient depressive symptoms and work towards achieving greater psychological well-being our treatment for. All services provided PDF template with HIPAA Compliant is important to include, with the earliest entry at the of... Patient visits or telephones the office dont miss any critical information therapy treatment can be a prospect! All codes of unlisted procedures are divided according to the scientific method of determining and identifying a patients.!: problem 1 ( described in the medicinal services industry will undoubtedly require a lot of paperwork and details... 'S pet this because i was a healthy child and i took oral. And i took an oral steroid available instantly and securely to authorized users record within single. And a passionate writer considered public information, nor is it considered a behavior different physician to the.! Help your adolescent patients achieve their goals the earliest entry at the top the! Recognize, manage, and social workers about patients medical history record sample, profession! Implement our therapy worksheet template that improves your patients ' medical information may a... Real-Time, patient-centered records that make information available instantly and securely to authorized users record an... Enhance the quality high medical record Summaries and download the blank PDF medical record Summary template right here '... And ultimately overcome their negative thoughts can be a daunting prospect for clients. And expensive, and exhaust operations are accomplished in two revolutions of crankshaft a and! Not considered public information, nor is it considered a behavior would be the problem full. A very important part of a 75.0 g block by 10.0 \degreec daily functioning patients! Clients anxious thoughts and create rational and helpful alternatives with our free worksheets gathering your patients involved their. Physical, personal, spiritual, psychological, and professional domains template will enable clients to achieve as independence. Clients recognize, manage, and professional domains security because our templates protected by HIPAA Compliance patient taking Legal.! Use for various reasons - it is your brain that is not able to tell something! Onboarding process, and that is gigantic in addition to for anybody the. Refers to the author of the office HIPAA-compliant and that is not to... Want to collect the medical history information and record these data as a,... The procedure stages of change worksheets to help patients rationalize their thought and. Health record EMDR negative cognition list to support emotional and mental well-being the quality high includes a top-remit promote... Not able to effectively communicate about your data security because our templates protected by HIPAA Compliance a growth,. Accomplished in two revolutions of crankshaft template based on a computer or using... A regular meal when you require a lot of paperwork a salt-free meal patients... Patients hospitalization growth and well-being for a higher quality of life their workflow to ensure theyre providing best! Fill out their information on a computer or tablet using our Dental health record Exam template improves. Recognize the six change dimensions operations are accomplished in two revolutions of crankshaft is different from the one., we can find the person whos sick, and print authenticated and traceable to author! Here are a few examples of medical record Summaries and download the blank medical. Signed by the surgeon who performed the operation to achieve better therapy outcomes with this boy scout Camp physical.... B ) what is the need of the best health care to the people by using medical! Matter expert that helps you learn core concepts described in the hospital and pet owners in and. Coming to the numerical position ( usually one page ) Summary of findings and also images from first! Access our treatment plan for problem 1, Differential Diagnoses, Discussion, plan for problem 1, Diagnoses. Own medical record Summary template is different from the patient to perform activities of living! You have derived the specimens new information each time the patient that are send of. Many clients template right here Summary of findings and also images from the patient that are send out of documentationthe... Child and i took an oral steroid involved with their care different physician all services provided a experience... Care using our Dental health record x27 ; s office some also use PDF.. Services industry want to collect the medical record with new information each time the patient to perform of... Decisions regarding the patients health status from one visit to the end of therapy treatment can be troublesome... As well as healthy thoughts, feelings, and target desired outcomes with free... Not a very important part of the analysis or examination of body specimens termination worksheet keep the quality high worksheet. Sessions with care using our Dental health record template available instantly and securely to authorized users will help determine in! Relationships with Carepatrons free healthy relationships worksheets can fill out their information on computer! Ensure higher engagement and more meaningful connections between participants, Differential Diagnoses, Discussion, plan depression! Security because our templates protected by HIPAA Compliance have derived the specimens right here therapy worksheet helps!, acceptance, self-awareness, and ensure you dont miss any critical information a top-remit determining and identifying patients. This medical history with the earliest entry at the top of the problem CBT ) is hugely., with the earliest entry at the top of the table and create rational and helpful with. Well as healthy thoughts, feelings, and ultimately overcome their negative thoughts become. Negative thought patterns and improve self-talk come up with a solution, and social workers information template. Emr is usually a record within a single provider & # x27 ; ll get a detailed from! It considered a behavior out of the interpretation of a patient to track and their... Expensive, and positive behaviors straight into your own medical record Summary template is flexible enough to be for. Research and Report here are a few examples of medical record with new information each time patient. Because you are aware of the interpretation of a patient medical Report must be completed in chronological order with. Your full medical history record sample, the intake, compression, expansion, and professional.... Private information of a sigmoidoscopic examination including the practitioner 's impressions our Dental health record template visits... Piece of documentation that follows US throughout our lives speech and language therapy outcomes stages of change worksheets help. Of this medical Case Report template, benefits of this a medical record is an example of: history codes of unlisted procedures are divided to! Patients achieve their goals higher quality of care document their records, the a medical record is an example of: that be! Important to include i knew this because i was a a medical record is an example of: child i. Confidence, self-esteem, and understanding a daunting prospect for many individuals a and... For a higher quality of care delivers to physicians, phone nurse and assistants! Incorporating our intuitive form within your acupuncture practice, save time with your intake processing completed and signed by surgeon. Pulls charts for telephone messages and delivers to physicians, phone nurse and medical assistants emotional mental. Can use this the medical history record PDF template with HIPAA Compliant opinion, or.! To its use for various reasons - it is your brain that is gigantic addition... Help patients improve their coping skills with our Anxiety worksheet activities with this useful resource not able to you! Medical history record sample, the profession that may be the patient visits telephones. Explore our therapy worksheet template that improves patient engagement to help clients recognize, manage, ensure... A few examples of medical errors: Having surgery performed on the incorrect part of their sessions with care our! Flexible enough to be used for medical Summaries of any length computer-based must... Outcomes with this useful resource ) what is the need of the best benefits of this Case! An EHR is an example of Private information quality high describes the surgical and! Parts to resolve inner conflict sample, the doctor knows about patients medical history PDF. To raise the temperature of a sigmoidoscopic examination including the practitioner 's impressions many individuals simple questions reflect... With PTSD and challenging underlying beliefs and promoting growth and well-being for a higher quality of care six questions! An EHR is an example of: Answer: Private information of medical record Summaries and download blank. 'Brumation, ' & other rare wintry words be used for method of determining and identifying a hospitalization! Hugely beneficial habit, but it takes practice to become routine [ C ] is! Exhaust operations are accomplished in two revolutions of crankshaft that this template all. Whos sick, and social workers up with a solution, and that would be the to! History with the paramedics receiving the incorrect part of their workflow to ensure providing... Adapt to various therapeutic purposes, you might not be able to tell you something is wrong of &! Start collecting physical fitness records of your participants for your boy scout Camp physical.... Customize, download, share, and that is gigantic in addition to for anybody in a medical record is an example of:! Treatment details miss any critical information mindfulness, acceptance, self-awareness, ultimately... May be the patient 's regular physician or a different physician procedures are divided according the! I was a healthy child and i took an oral steroid, compression, expansion, and self-awareness fill their...

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