Represents documentation of the patient's current and past health status? Medical history. Contains the physician's findings based on an examination of the patient? Physical exam. What is the function of a consultation report?
Represents the attending physician's assessment of the patient's current health status? Physical Examination. Patient history questionnaires are most often used in: Ambulatory Care.
Documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record? Personal Health Record. Which type of patient care record includes documentation of a family bereavement period? Hospice Record.
Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient Rationale: Documentation standards ensure that the health record records the treatment provided to the patient. 20. True or false?