medical documentation

medical documentation

A term relating to a patient care or medical record. Typically, medical documentation consists of operative notes, progress notes, physician orders, physician certification, physical therapy notes, ER records, or other notes and/or written documents; it may include ECG/EKG, tracings, images, X-rays, videotapes and other media.

medical documentation

Managed care A term relating to a Pt care record or medical record, which may be written and include EKG, tracings, X-rays, videotapes and other media; typically, operative notes, progress notes, physician orders, physician certification, physical therapy notes, ER records, other notes and/or written documents are included