Medical Charts
Definition
A medical chart is a confidential document that contains detailed and comprehensive information on an individual and the care experience related to that person.
Purpose
The purpose of a medical chart is to serve as both a medical and legal record of an individual's clinical status, care, history, and caregiver involvement. The specific information contained in the chart is intended to provide a record of a person's clinical condition by detailing diagnoses, treatments, tests and responses to treatment, as well as any other factors that may affect the person's health or clinical state.
Demographics
Every person who has a professional relationship with a health-care provider has a medical record....
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