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Quiz: The Composition & Organization of a Medical Record

  1. A medical record is always extremely complex containing a variety of reports, many of which are handwritten.
  2. The work of abstracting medical records would be more difficult if an abstractor is unfamiliar with medical terms, the physician's handwriting, and the diagnostic procedures.
  3. While patient identification, geographical information, and medical history are contained in most medical records, treatment and follow-up reports are not.
  4. All hospitals follow the same procedures for organizing a medical record.
  5. Usually, a medical record is organized in terms of the temporal sequence of events with the latest admission located at the front of the medical record.
  6. An abstractor should abstract from the point of view of the attending physician.