The Health Record Is Defined as the _____ Record Generated

question 24

Multiple Choice

The health record is defined as the _____ record generated at or by the health care provider or organization,which documents treatments and services delivered during the patient's episode of care by the provider or organization.

• A) Business
• B) Legal
• C) Medical
• D) Valid

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Definitions:

Physical Assessment

An examination of the body by a healthcare professional to determine the presence or absence of physical signs of disease or injury.

Baseline Data

Initial information gathered before a project or phase of a project begins, used as a reference point for future comparisons.

Nursing Diagnoses

Clinical judgments about individual, family, or community experiences and responses to actual or potential health problems, providing the basis for selecting nursing interventions.

Substernal Chest Pain

Describes pain located beneath the breastbone, often related to heart conditions but can also result from gastrointestinal issues.