INTRODUCTION 1.1 Background to the Study People generally assume all communications between them and their doctor or other health professionals will remain private ,and the law generally reflects this expectations .If it were not so, some people might feel reluctant to seek medical treatment, patients may be less honest in describing their ailments , patients may give inaccurate or incomplete information in their medical histories, ask their physician not to record embarrassing inform...
ABSTRACT Documentation in medical record is the basis for communication between health professionals which inform the care provided, the treatment rendered, care planned and the outcome of that care as a continuous and existing record. Health information documentation is a document about healthcare services that is provided to an individual patient. If documentation doesn’t give a clear presentation of a patient’s history, it is termed improper documentation. Thus, this study aims to dete...
