Page 22 - Law And Rules Regarding Medical Record
P. 22
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Elements Of Documentations In Medical Records
• Doctor’s clinical notes
• Recording of Discussion with patient /next of kin regards disease/ management (with witness) /
Possible use of tape recording for such discussions
• Referral Notes to other specialist(s) for consultation/management
• Laboratory & Histopathological reports
• Imaging records and reports
• Clinical Photographs
• Drug Prescriptions
