Documentation And Record Keeping
Objectives
After completing the module, you ill be able to
• Explain the importance of Record Keeping
• List the types of Medical Records
• Enumerate the uses of Medical Records
Introduction
Medical records are both medical and legal. -Record can be defined as Documentary Evidence of any fact or an event. In case of medical records it pertains to documents containing patient's history, clinical findings investigations, operation notes & day wise progress. Legally, they are required by courts of law and insurance companies in settlement of disputes.
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