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What are the components of medical record file?

Sagot :

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Answer:

  • Introduction. Components of a Complete Medical Record. ...
  • Identification. Identification. ...
  • Date, History. Date, History. ...
  • Physical Exam. Physical Exam. ...
  • Assessment. Assessment. ...
  • Informed Client Consent. Informed Client Consent. ...
  • Medical Treatments. Medical Treatments. ...
  • Surgical Treatments, Anesthesia. Surgical Treatments, Anesthesia.

Explanation:

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Answer:

See below

Explanation:

A medical record contains:

Medical History (H&P = History and Physical)

Lab Test Results

Diagnostic Test Results

Problem List

Clinical Notes

Treatment Notes

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