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Clinical Component This component of an EHR enables physicians to document key information such as patient history, operative notes, consults, and more. Clinical components of an EHR can also include sub components for pharmacy and nursing details.
Purposes of Patient Records Patient Care. Patient records provide the documented basis for planning patient care and treatment. Communication. Legal documentation. Billing and reimbursement. Research and quality management.
How long does a physician need to retain medical records? There is no general law requiring a physician to maintain medical records for a specific period of time.
Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. At the end of the day, thats what really matters. Good documentation is important to protect you the provider. Good documentation can help you avoid liability and keep out of fraud and abuse trouble.
Documentation communicates the what, why, and how of clinical care delivered to patients. These records allow other clinicians to understand the patients history so they can continue to provide the best possible treatment for each individual.
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A personal health history (conditions, how theyre being treated and how well theyre controlled, as well as important past information such as surgeries, accidents and hospitalizations) Doctor visit summaries and notes. Hospital discharge summaries. Pharmacy printouts that accompanied prescribed medications.

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