Medical Record Keeping
The medical record is a powerful tool that allows the treating physician to track the patient’s medical history and identify problems or patterns that may help determine the course of health care.
The primary purpose of the medical record is to enable physicians to provide quality health care to their patients. It is a living document that tells the story of the patient and facilitates each encounter they have with health professionals involved in their care.
In addition to telling the patient’s story, complete and accurate medical records will meet all legal, regulatory and auditing requirements. Most importantly, however, they will contribute to comprehensive and high quality care for patients by optimizing the use of resources, improving efficiency and coordination in team-based and interprofessional settings, and facilitating research.