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Past surgical and hospitalization procedures. Medical tests, lab results and their findings (blood panels, X-rays, endoscopy, etc.) Provider notes and/or patient instructions following exams, visits, and consultations. Statistics such as height, weight, and blood pressure on a set date or graphed over time.
What are examples of clinical documents?
Clinical documents serve as a thorough and organized record of a clients mental health treatment journey. Records include information such as demographics, assessment data, treatment plans, session progress notes, homework assignments, tracking forms, and progress reports.
What is hospital paperwork?
There are a number of forms you are required to fill out for every hospital visit. You will need to provide information such as your personal details, Medicare card and other health information to the hospital. Your health record is the document that details your medical history and medical care over a period of time.
What counts as medical documents?
A health record (also known as a medical record) is a written account of a persons health history. It includes medications, treatments, tests, immunizations, and notes from visits to a health care provider.
What is the purpose of hospital documents?
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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What is a hospital document?
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).
Related links
The Guide to Getting and Using Your Health Records
It includes medications, treatments, tests, immunizations, and notes from visits to a health care provider. Most hospitals and other large health care providers
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