What are the two major types of documentation in a health record?
We can differentiate between clinical and non-clinical documentation. Clinical documentation is the patient’s information that includes their biological history and all the information that the healthcare professional attending the patient should be aware of.
What is a health record what is it used for quizlet?
The health record is known by different names in different healthcare settings. However, no matter what term is used, the primary function of the health record is to document and support patient care services.
What are the two primary purposes of a medical record?
Purpose and definition of the Legal Medical Record
Describing the services provided to the client. Providing evidence that the care was necessary.