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DOCUMENTING. A report: is oral, written, or computer-based communication intended to convey information to others. For instance, nurses always report on clients at the end of a hospital work shift.. DOCUMENTING. A record: is written or computer-based. All personnel involved in a patient's health care contribute to the medical record by charting, recording, or documenting (process of writing information) on the health agency's forms. Medical record, also called a chart or client record, is a for9454
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