Health Information Management Terminology
Write a short, 1–2 page paper on some of the types of documentation used in the Health Information Management field. Be sure your paper includes all of the following headings:
· Progress Note.
· History and Physical (H&P).
· Operative Report.
· Discharge Summary.
Under each heading, address each of the following
· Describes the purpose and contents of some of the types of documentation that are part of the health record, and provides examples to show the impact of incomplete and inaccurate health records.
· Detail the contents included.
· Identify settings where the document would be used and provides examples to show the impact of failing to consistently use complete and accurate health records.
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