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The Medical Record

The medical record is one of, if not THE, most important documents within the delivery of healthcare services.It is what tracks the course of a patients care. It allows medical providers to review a patients medical history as well as plan a course of care for the future.

It is a communication tool that not only provides clinical data regarding a patient’s current and past medical history, but is also used in the reviewing and reimbursement of insurance claims, and to review utilization and quality of care.

The Contents of a Medical Record

* Face sheets, encounters for each visit
* Vital Signs
* Physician’s orders
* History and Physical forms
* List of Medical Problems
* Medication Lists
* Progress Notes
* Discharge Summary
* Authorization Forms
* Diagnostic Testing
* Laboratory Testing
* Operative Reports
* Pathology Reports

Documentation

Documentation is the most critical function regarding keeping accurate medical records, as it records all of the important details and facts regarding a patient’s care.

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