Asked by M Luisa TS Nen on May 09, 2024
Verified
Recording information in the medical record is called ____.
A) transcription
B) description
C) dictation
D) filing
E) documentation
Medical Record
A comprehensive file containing a patient's personal, medical, and treatment history, used by healthcare providers for continuity of care.
Documentation
The act of recording information, events, or processes in a systematic manner, often for legal, historical, or informational purposes.
- Understanding the responsibilities of healthcare professionals in maintaining accurate and up-to-date patient records.
Verified Answer
GM
Gennaro MazzellaMay 15, 2024
Final Answer :
E
Explanation :
Documentation is the correct term for recording information in the medical record. It involves the detailed recording of patient encounters, treatments, medical histories, and other relevant health information.
Learning Objectives
- Understanding the responsibilities of healthcare professionals in maintaining accurate and up-to-date patient records.
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