Which term describes the systematic collection of patient health data and records?

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The systematic collection of patient health data and records is best described by the term "medical documentation." This process involves recording and organizing a patient's medical history, treatment plans, progress notes, and other relevant health information in an accurate and standardized manner. Medical documentation serves several purposes, such as ensuring continuity of care, providing a legal record of treatment, and facilitating communication among healthcare providers.

While patient assessment involves the evaluation of a patient's health status and needs, it is more focused on the process of collecting information at a specific point in time rather than the ongoing recording and management of that data. Clinical evaluation often pertains to the analysis and interpretation of health data to make diagnostic or treatment decisions but does not encapsulate the entire spectrum of systematic data collection and record-keeping as medical documentation does. Health history refers to the specific data regarding a patient’s past and present health status but, like patient assessment, is not as comprehensive or structured as the overall practice of medical documentation.

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