Which of the following is true about medical records quizlet?
Which of the following is true about medical records? They provide a written account of a patient's health care. Medical records can be used for legal purposes to protect patients and medical professionals.
What is a health record what is it used for quizlet?
The health record must include the following data elements: Patient identification, consents for treatment, advance directives, problem list, diagnoses, clinical history, diagnostic test results, treatments and outcomes, conclusions and follow-up requirements.
Which of the following best describes the most important function of the health record quizlet?
Terms in this set (15) Which of the following best describes the most important function of the health record? Storing patient care documentation is the most important function of a health record. As a result, clinical professionals who provide direct patient care are the primary users of the health record.
What information should be included in a patient's medical records quizlet?
Information on a patient such as, demographics, progress notes, problems, medication, vital signs, past medical history, immunizations, laboratory data, radiology pictures, and other personal data (height, weight, and billing information). Information that is provided by the patient and then updated as necessary.
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