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The patient record shall indicate:

A) Date and nature of service provided
B) Name, date, medical dx
C) Name and titile of who provided service
D) A and C

1 Answer

2 votes

Final answer:

The patient record must include the date and nature of service, as well as the name and title of the service provider, making option D the correct choice. Proper documentation and use of ICD codes are essential in healthcare for treatment and communication purposes. Privacy concerns also play a critical role in policy development regarding health records.

Step-by-step explanation:

The patient record shall indicate the date and nature of service provided, as well as the name and title of who provided the service. This means that the correct answer to the question is D) A and C. Adding to this, for healthcare, proper documentation is essential for both clinical and legal purposes. For example, when documenting a surgical procedure, it is crucial to record the name of the procedure, verify that all counts for needles, sponges, and instruments are complete, and ensure any specimens are correctly labeled.

Furthermore, when treating a patient, the use of ICD codes is crucial for identifying treatments and facilitating communication between healthcare providers, medical labs, and insurance companies. ICD codes are also used by epidemiologists and vital-records keepers. Lastly, the privacy of health records must be carefully weighed against the costs of treatments and the quality of patient care when developing policies around electronic health records.

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