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2012 4.4 Satisfied (50 Votes)
2007 4 Satisfied (44 Votes)
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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).
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.
You will receive paperwork called an After-Visit Summary, or AVS. It goes over your condition, medications, follow-up appointments and any other information you need.
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.
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.
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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.
Hospital discharge summaries serve as the primary documents communicating a patients care plan to the post-hospital care team. 1, 2. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care.

hospital paperwork pdf