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Documentation
Written or printed material that provides official information or evidence, or that serves as a record.
Problem-Oriented Medical Record (POMR)
A method of recording healthcare information that organizes data by the patient's specific problems, facilitating a systematic approach to treatment.
Initial Interview
The first meeting between a healthcare provider and a patient, aimed at discussing health concerns and medical history.
Release-of-Records Form
A document signed by a patient that authorizes the disclosure or sharing of their medical records with specified parties.
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