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Author Question: Health records are classified as primary or secondary records. Give an example of each type. What ... (Read 106 times)

stevenposner

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on: Jul 12, 2018
Health records are classified as primary or secondary records. Give an example of each type.
 
  What will be an ideal response?

Question 2

An electronically signed document is sealed, which means what may happen?
 
  A) It may be amended if necessary.
  B) It may now be edited extensively.
  C) It may not be modified or amended in any way.
  D) It may be viewed only by the recipient of the document.


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annierak

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Reply #1 on: Jul 12, 2018
Answer to Question 1

Primary records are those that are gathered directly from the patient and his or her provider. Examples include patient history, SOAP note, doctor's notes, admission or discharge reports, nursing notes, orders, lab results, radiology reports, patient history, problem list, medications list, as well as data obtained from devices.
Secondary records are those that are created later when analyzing, summarizing, or abstracting from the primary records. Examples include the master patient index, insurance claims, patient bills, and aggregate data used for research and statistical reports (ALOS was given as an example).

Answer to Question 2

A


stevenposner

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Reply #2 on: Jul 12, 2018
Thank you


annierak

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Reply #3 on: Jul 12, 2018
No problemo


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