Q:
How would you document a patient's medical history?
Answer
Medical record documentation is required to record pertinent facts, findings, and observations about a veteran’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
• The medical record documents the care of the patient and is an important element contributing to high quality care.
• An appropriately documented medical record can reduce many of the hassles associated with claims processing.
• Medical Records may serve as a legal document to verify the care provided.
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