documentation processes

How is Patient Information Documented?

Patient information is documented using electronic health records (EHRs) and paper-based systems, though the former is becoming more prevalent. EHRs offer numerous advantages, such as easy access to patient data, reduced risk of errors, and improved coordination of care. They typically include demographic information, medical history, diagnosis, treatment plans, laboratory results, and patient-reported outcomes. In cancer care, specific details about the type, stage, and grade of cancer, as well as treatments administered, are meticulously recorded.

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