Purposes of Medical Records
A medical record provides continuity of care between providers and other healthcare professionals by documenting the patient's history, diagnoses, and treatments.
Module 5: Contents of the Medical Record
Purposes of Medical Records
Types of Medical Records
Learn about the types of medical records that you're likely to see.
Chart Notes
A chart note, or progress note, is a complete, narrative description.
SOAP
Documenting patient encounters in the medical record is an important part of the practice's workflow.
Subjective Examples
Here for routine follow up.
Example of a Progress Note
Example of a Progress Note
History and Physical (H&P)
A history and physical (or H&P) helps the physician make a diagnosis.
Sections of an H&P
Sections of an H&P
Common H&P Terminology
Common H&P Terminology
Example #1
Example #1