n South African Medical Journal - Audit of medical records : use of a structured form in emergency departments : correspondence




Medical records may be considered to be any information and documents kept in a systematic, scientific and easy way that help clinicians retrieve the required data on a patient at the time it is needed. They can cover a wide range of material including handwritten notes, computerised records, correspondence between health professionals, laboratory reports, imaging reports, videos and printouts from monitoring equipment.


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