Healthcare Documents

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Commonly Asked Questions about Healthcare Documents

What are the three common types of medical records?

There are three types of medical records commonly used by patients and doctors: Personal health record (PHR) Electronic medical record (EMR) Electronic health record (EHR)

What are 3 examples of medical office administrative documents?

Some forms are still used in paper format, including for example, medical history surveys, consent forms, medical charts, letters, and memos. The medical office administrative assistant is responsible for accurate documentation and maintenance of patient medical office records.

What are the types of medical documents?

Types of Medical Records EHR (Electronic Health Records) EHRs are comprehensive digital records that consolidate your health information in one secure location. PHR (Physical Health Records) Medical History Records. Medication Records. Immunization Records. Laboratory and Test Results. Progress Notes. Surgical Records.

What is documentation in healthcare?

Documentation typically reports why the patient was seen, what assessment or treatment was provided, clinical findings (e.g., diagnoses), and what (if any) treatment was recommended and provided in a way that justifies the assigned diagnosis and procedure codes (see Coding for Reimbursement).

What are examples of source documents in healthcare?

Common source documents are participant medical records, phone encounters or notes, lab and diagnostic test results, participant diaries and specific research worksheets used to document key research data elements. If data are entered directly into a computer system, the electronic record is considered the source.

What counts as medical documents?

Typical medical records include: Patient identification, contact information, and date of birth. Billing and health insurance details. List of current and chronic ailments and diagnoses.