What information is included in a health record?
A health record (also known as a medical record) is a written account of a person's health history. It includes medications, treatments, tests, immunizations, and notes from visits to a health care provider.
What are the 12 main components of the 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. If written correctly, notes will support the doctor about the correctness of treatment.
What are 5 different things that you may find in a patient's medical records?
Data types commonly extracted from EHRs and imported into registries are patient identifiers, demographics, diagnoses, medications, procedures, laboratory results, vital signs, and utilization events.
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