What are the two most common types of medical records?

There are three types of medical records commonly used by patients and doctors: Personal health record (PHR) Electronic medical record (EMR) Electronic health record (EHR)

What are types of documentation records?

Types of Records
  • I. Administrative Records. Records which pertain to the origin, development, activities, and accomplishments of the agency. …
  • II. Legal Records. …
  • III. Fiscal Records. …
  • IV. Historical Records. …
  • V. Research Records. …
  • VI. Electronic Records.

What are the four main parts of a medical record?

Doctors are all different and take notes in their own style, so medical records can greatly depend on the medical staff that created them. However, some unified components exist in nearly every complete medical records.

Patient’s Medical History
  • Past and present diagnosis.
  • Medical care.
  • Treatments.
  • Allergies.

What are examples of records?

Record (Official Record)

Any papers, books, photographs, magnetic tapes, machine readable materials, microfilm, or other materials which document official actions, decisions, policies or procedures.

What is the most common types of medical record formats?

What are the two most common types of medical records? Paper-based medical records and electronic medical records are the two most common types of medical records.

What are the three main types of records?

The following sections will provide general guidance on the disposition of 4 types of records:
  • Temporary records.
  • Permanent records.
  • Unscheduled records.
  • Records on legal hold.

What are the different types of documentation in early childhood?

Katz and Chard offer this explanation: “Documentation typically includes samples of a child’s work at several different stages of completion: photographs showing work in prog- ress; comments written by the teacher or other adults working with the children; transcriptions of children’s discussions, comments, and explana …

What are the types of records in nursing?


What are the types of clinical documentation?

These documents include treatment and observation notes, care plans, correspondence, test results, x-rays, clinical photos, medication charts, checklists, operation reports, transfer forms, clinical summaries and information from specialists, community workers or general practitioners.

What is the main purpose of documentation?

Documentation refers to a set of records that professionals or companies keep to provide evidence or information that can be used to inform decisions. In the workplace, documentation is retained records of employment and company actions and events as required by legal mandates and company policy.

Why is documentation so important?

In every field, it’s important to minimize as much risk as possible. Documentation is a great tool in protecting against lawsuits and complaints. Documentation help ensure consent and expectations. It helps to tell the narrative for decisions made, and how yourself or the client responded to different situations.

What are two types of documentation?

Documentation can relate to two different types: products and processes. Product documentation describes the product under development and provides guidelines on how to execute actions with it. Process documentation, on the other hand, relates to all the material created during development.

What is document process?

Process documentation is the method of internally capturing all the information necessary to properly execute a business process within your organization. It is a continuous activity that must be carried out as processes are built in order to ensure delivery of the desired outcome.

What is the difference between document and documentation?

“Document” means a specific collection of words you can point to, either sitting on a table or in a computer. Eg, a book or manual. “Documentation” means a somewhat looser collection of words, possibly scattered across a desk or across the interweb.

What are the 4 kinds of documents?

The four kinds of documentation are:
  • learning-oriented tutorials.
  • goal-oriented how-to guides.
  • understanding-oriented discussions.
  • information-oriented reference material.

What are the five common types of documentation?

Types of Documentation

Types of system documentation include a requirements document, source code document, quality assurance documentation, software architecture documentation, solution instructions and a help guide for advanced users.

What are the 7 types of documents?

The 7 types of documents you should never throw away!
  • WORK DOCUMENTS. Tax forms, vacation time, proof of educational leave, etc. …

What is a standard document?

Standard document is defined as “a document approved by a recognized body that provides, for common and repeated use, rules, guidelines, or characteristics for products or related processes and production methods, with which compliance is not mandatory.