In: Nursing
A document that reveals all details about the patient ,such as history, clinical findings, laboratory results, procedures details and care provided with progression notes and medications orders is known as medical record.
Medical records are written in a logical method, and according to the time and date.The information in the medical recors help the health care workers to identify the patients medical history and the care advised. Medical records are universally accepted and it is confidential and never disclose without patients consent.
In a nutshell medical records are used for the purpose as documentary evidence, for the patient future care ,to evaluate treatment effectiveness and also for research and education.
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