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Importance of Medical Records

Posted on:7/12/2012
The medical record in its entirety is a written chronicle of the medical and nursing care that a patient has received or is expected to receive over a period of time and a record of those who provided that care.


The medical record in its entirety is a written chronicle of the medical and nursing care that a patient has received or is expected to receive over a period of time and a record of those who provided that care. This includes care prior to admission to an institution, care while in the institution or an anticipated course of treatment after discharge.

 

Medical records are first and foremost a medical document and second a legal document. As a legal record, it will provide evidence of the type and quality of care that a patient received at the hands of those caregivers whose orders, progress notes and various reports are included in it. 

 

The record will confirm that the patient has been properly identified, assessed and admitted to the institution. The record will reflect timely and proper medical and nursing intervention and treatment based on medical diagnoses. The record must have complete and accurate documentation of such intervention and treatment. The institution must retain the medical records for the time prescribed by the Department of Health and Human Services.

 

Medical record establishes a legal record to protect the rights and interests of the patient, the institution and the providers of care. The contents of a medical record have great significance in a medical accident lawsuit. The adequacy of the record can make or break a case. If the medical record demonstrates deficiency in care or breach of duty, it will play a significant role in deciding the case in favor of the plaintiff.


  
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