Contents of Medical Record
Posted on:3/24/2006
| Although the specific content of the medical record may vary depending upon specialty and location, it usually contains the patient's identification information; the patient's health history (what the patient tells the health care providers about his or her past and present health status); and the patient's medical examination findings. |
Although the specific content of the medical record may vary depending upon specialty and location, it usually contains the patient's identification information; the patient's health history (what the patient tells the health care providers about his or her past and present health status); and the patient's medical examination findings (what the health care providers observe when the patient is examined). Other information may include lab test results; medications prescribed; referrals ordered to health care providers; educational materials provided; and what plans there are for further care, including patient instruction for self-care and return visits. In some places, billing information is considered to be part of the medical record.
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