MEDICAL DOCUMENTATION

Jul 4th, 2015
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Medical documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes.

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MEDICAL DOCUMENTATIONLegal MedicineSaturday 6-7pmDr. Joey MontemayorWhat is Medical Documentation?Medical documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. What is the purpose of Medical Documentation? The medical record is an evidentiary document generated for the main purpose of communicating to others what was done, why it was done and if not done, why it was not done. Importance of Medical Documentation - it will help them in the scientific evaluation of their patient profile, helping in analyzing the treatment results, and to plan treatment protocols; - It also helps in planning governmental strategies for future medical care. Kinds of Medical Documentation/ Records: -Patient History and Physical examination report-C

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