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Medical record notes, (also called chart notes, outpatient notes, or progress notes) are the formal or informal notes taken by the physician when he
Medical record notes, (also called chart notes, outpatient notes, or progress notes) are the formal or informal notes taken by the physician when he or she meets with or examines a patient in the office, clinic, acute care center, or emergency department. These notes are part of the patient's permanent medical record and are vital to effective patient care. Although medical records are used mainly to assist the physician with care of the patient, they can be reviewed by attorneys, other physicians, insurance companies, or the court. It is essential that the medical records are neat, accurate, and complete
- Explain how you identify the type of information that appears in various medical reports.
- When preparing various types of reports and other medical documents how do you know which formats are acceptable for each type of document? Explain using two examples.
- Describe one example of how missing documentation can affect patient care.
