Page 23 - Law And Rules Regarding Medical Record

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Elements Of Documentations In Medical Records

• Nurses’ Reports

• Consent Forms, At-Own-Risk Discharge Forms

• Operation Notes/Anaesthetic Notes

• Video Recordings

• Printouts from monitoring equipment (e.g. Electro-cardiogram, Electroencephalogram)

• Letters to and from other health professionals

• Computerized/electronic records

• Recordings of telephone consultations/instructions relevant to the care of the patient