HLT POL 100 Chapter Notes - Chapter 9: Digoxin, Electronic Health Record, Medical Record

• School: UCLA
• Department: Health Policy and Management
• Course: HLT POL 100
• Professor: Marcy Boroff

Document Summary

T he medical record is all of the written or electronic documentation relating to a patient. It includes past history information, current diagnosis and treatment, and correspondence relating to the patient. They provide a medical picture and record of the patient from birth to death. It is an important document for the continual management of a patient"s healthcare and furnishes documentary evidence of the course of evaluation and treatment. The patient record, which can result from a lifetime of medical visits, can assist the physician in diagnosing, treating, and tracking the patterns of the patient"s health. The medical record is a document that records both the care and treatment that a patient did and did not receive. The terms medical record and medical chart are used interchangeably. c. c. Lanoxin today for one dose only. the mother gave the baby 3. 0 c. c. as she was told to do by the doctor.