Ch 11 Flashcards
0
Q
The medical record holds what?
A
History and physical laboratory reports discharge summary and progress notes
1
Q
What describes the patient’s medical record?
A
A document containing subjective information. The one best source of medical information about the patient
2
Q
What sections of the medical record are used most by physicians for documentation purposes?
A
History physical and progress notes
3
Q
What is important in documenting in a patient’s medical record?
A
Document only facts be brief use medical terminology describe precisely what has occurred
