Module 5: Contents of the Medical Record

Purposes of Medical Records

Purposes of Medical Records

Complexity: Easy

A medical record provides continuity of care between providers and other healthcare professionals by documenting the patient's history, diagnoses, and treatments.

Chart Notes

Complexity: Easy

A chart note, or progress note, is a complete, narrative description.

SOAP

Complexity: Easy

Documenting patient encounters in the medical record is an important part of the practice's workflow.

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