Questions
1 2026-04-01
Introduction to Healthcare
✦ Chapter 19 –
Documentation & Medical
Records | Study Guide &
Practice Questions
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Introduction1to Healthcare ✦ Chapter 19 – Documentation & Medical Records _ Study Guide & Practice Questions.pdf
, Introduction to Healthcare Chapter 19 Documentation and Medical Records Page 2 2026-04-01
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Terms in this set (32)
Medical documentation refers to notes and documents that health care professionals add to
the medical record
Ex: patient statistics, patients diagnosis, results of tests, treatments
received, and medications
Medical record refers to the collection of all documents that are filed together and
form a complete chronological health history of a particular patient
commonly referred to as a medical chart or patient chart
Charting recording observations and information about patients
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