The Medical record documentation includes about the duration, timing, location, severity setting, sign and symptoms, quality and factors related to patient's illness.
This document is necessary for the ability of physician and healthcare doctors to evaluate and to plan the patient's treatment. For accurate review and payment and collection of data.
It should include the reason of the encounter , physical examination findings and diagnostic test result. It also plan for care and clinical impression.
Physician is a person who is specializes in medical treatment and diagnosis.
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