Documentation Basics Flashcards
0
Q
Medical Record
A
Contains the details of a patient’s healthcare visit
1
Q
Patient demographics
A
Include gender, employment, and social security number
2
Q
Healthcare documentation process
A
Process of creating and storing the medical record
3
Q
Clinical information
A
Medical information about the patient
4
Q
An example of a ___ is a fever
A
Symptom
5
Q
He nurse who admits of evaluates the patient in the emergency room is called the ___ nurse
A
Triage
