Health care facilities treat many types of patients. For hospitals, patients are called inpatients and stay overnight. For outpatient facilities, such as a clinic or ambulatory center, patients will arrive for an appointment, treatment, test, or procedure and then return home the same day. For a long-term facility, such as a nursing home, patients will stay for weeks or months—even years. Keeping a patient record of treatment rendered is most important to maintain a health care facility and support the reimbursement process to receive payment for services rendered. The patient record is a legal document. There is a saying in health care, “If it was not documented, it was not done.” This patient data can be in paper or electronic format.
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