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प्र: How would you document a patient's medical history?

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Medical record documentation is required to record pertinent facts, findings, and observations about a veteran’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. • The medical record documents the care of the patient and is an important element contributing to high quality care. • An appropriately documented medical record can reduce many of the hassles associated with claims processing. • Medical Records may serve as a legal document to verify the care provided.

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