What information should be included in a medical record?
Medical records are the document that explains all detail about the patient's history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress and medication.
What is in a medical report?
name, age and address. health conditions. treatments and medicines. allergies and past reactions to medicines.
What are 3 things you should not add to a medical record?
Information contained in the medical records is? Health History, Results of the Physical Examination, Lab Reports, Progress Notes.
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