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A medical certificate or doctor's certificate [1] [2] is a written statement from a physician or another medically qualified health care provider which attests to the result of a medical examination of a patient. [3] It can serve as a sick note (UK: fit note) (documentation that an employee is unfit for work) or evidence of a health condition. [4]
By leveraging a seasoned underwriter's knowledge and experiences, scripts can be built that ensure the appropriate medical information is captured and recorded from the APS document. [2] This is done by creating scripts that prompt the person summarizing the APS to enter all pertinent specific medical condition uncovered.
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The doctor can on occasion refill the patient's medications after seeing only the medical record, although doctors prefer to not refill prescriptions without seeing the patient to establish if anything has changed. It is very important to have a properly formatted, edited, and reviewed medical transcription document.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
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