medical record Flashcards
1
Q
What are the 7 patient’s right in the USA?
A
- treated with respect
- obtain medical record
- privacy of your medical records
- make treatment choice
- informed consent
- refuse treatment
- make decisions about end of life care
2
Q
What is a medical record?
A
Is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization
It has to physically exist in separate and multiple paper-based or electronic systems
Explains all the details of patients history, clinical findings, diagnostic results, pre and post operative care, patients progress and medication.
3
Q
If the medical record is well written—-
A
it will support the correctness of treatment
4
Q
Who uses medical records?
A
Hospitals physicians pharmacies specialists labs primary care
