solutions A+ rated
Medical Record: Clinical must....... - correct answer ✔✔- organize
- synthesize
- record data along w/ problems identified
- rationale for diagnostic eval & plan of care
Medical record: Functions include..... - correct answer ✔✔• Order entry
• Risk stratification
• Population health reporting
• Provision of care pathways
• Exchange of health info among different healthcare systems
Importance of Medical Record - correct answer ✔✔Clear
Concise
Comprehensive
Relevant
Succinct
*CCCRS*
DO NOT - correct answer ✔✔purposefully omit vivid details of the exam in your notes
Medical record: LEGAL DOCUMENT - correct answer ✔✔ANY information contained may be:
- Used in court
- in legal proceedings