The contents of inpatient medical records provide evidence of a patients care from admission to discharge (e.g.,
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The contents of inpatient medical records provide evidence of a patient’s care from admission to discharge (e.g., admission record, authorization for treatment forms, advance directives, history and physical examination, treatment plans, physicians’ orders, progress notes, nursing notes, diagnostic reports, consultation reports, vital signs charts, anesthesia assessments, operative reports, medication administration records, discharge planning documentation, patient education, and discharge summary).
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Related Book For
Legal Aspects Of Health Care Administration
ISBN: 9781284231526
14th Edition
Authors: George D. Pozgar
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