1. Doctor’s office records: no consistent form or format. Usually has visit notes, summary of hospitalization, outpatient notes, communication notes, lab tests/results.
2. Hospital/Facility records: unlike ordinary outpatient records, these have to conform to certain standards. Info found includes administrative or personnel information on billing, consent forms, committee records. Admission records include status of patient on admission, records or progress notes on patient’s daily care. Notes from dieticians, nurses, etc. Lab records. Discharge summary is a summary of admission in hospital, course in hospital, final diagnosis and post-discharge plan.
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