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Healthcare Information Technology Exam Guide for CompTIA Healthcare IT Technician and HIT Pro Certifications by Brian Gugerty, Kathleen McCormick

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The Patient’s Medical Record

The patient’s medical record, whether in paper or electronic form, contains vital clinical information to support the diagnosis and justify the care and treatment rendered to the patient. This information includes the patient’s medical history, physical examination results, radiology and laboratory reports, diagnoses and treatment plans, as well as orders and notes from doctors, nurses, and other healthcare professionals. The quality and integrity of the information contained in the patient’s medical record is essential for clinical, legal, and fiscal purposes, for correct and prompt diagnosis and treatment of the patient’s condition, and for continuity of care.

Although the primary use of the patient’s medical record ...

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