Section 1: Health Records, Content & Documentation

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5 Terms

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Primary data

is captured at the direct point of care by clinicians.(includes the EHR itself, progress notes, and History & Physical (H&P)

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Secondary data

is pulled and abstracted from primary sources for administrative, legal, or research purposes (e.g., registries, indices, MEDPAR, vital statistics).

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H&P (History and Physical)

24 hours completed

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Discharge Summary

30 days of discharge

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Operative Notes

Possess strict, immediate postoperative timing rules.