Medical record entry

Something written in the medical record. Certain members of the health care team, such as physicians, nurses, respiratory therapists, physical therapists, etc., are permitted by the hospital to write in the medical record. Each person doing so follows a certain protocol, which includes dating the written information and authenticating (signing) it (see authenticate). Customarily, a notation made by one person at one time is called an entry. “Written” may include computer and audio entries; any type of recording approved for that hospital’s medical record system.


 


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