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Questions and Answers
What is the first information to be fulfilled in a medical record or clinical note?
What is the first information to be fulfilled in a medical record or clinical note?
- Patient's ID number (correct)
- Patient's date and time of visit
- Doctor's name and position
- Patient's chief complaint
What should the chief complaint in a medical report primarily include?
What should the chief complaint in a medical report primarily include?
- Doctor's own summary phrase
- Abnormal exam/lab findings
- Patient's own words about the symptoms (correct)
- Diagnosis established before the patient arrived
What should be included in medical records according to the text?
What should be included in medical records according to the text?
- Every consultation by email or letter only
- Only physical consultations
- Every consultation by telephone, video, email, or letter (correct)
- Every consultation by telephone or video only
What distinguishes an original medical report from a medico-legal report according to the text?
What distinguishes an original medical report from a medico-legal report according to the text?
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What is a requirement for writing a medical report according to the text?
What is a requirement for writing a medical report according to the text?
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