NURSING EXAM QUESTIONS
HEALTH INFORMATICS
|
Question
[CLICK ON ANY CHOICE TO KNOW THE RIGHT ANSWER]
|
Which of the following elements should be included in a medical record?
|
|
complete medical and treatment history
|
|
|
family medical history
|
|
|
personal identifiable information
|
|
|
all of the above
|
Explanation:
Detailed explanation-1: -It usually contains the patient’s health information (PHI) which includes identification information, health history, medical examination findings, and Medical billing information. Medical records were traditionally kept in paper form, with tabs separating the sections.
Detailed explanation-2: -An electronic medical record includes information about a patient’s health history, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans.
Detailed explanation-3: -Administrative and billing data. Patient demographics. Progress notes. Vital signs. Medical histories. Diagnoses. Medications. Immunization dates. More items •09-Apr-2019
There is 1 question to complete.