Jun 22, 2018
Medical and Health Records: Risk Issues and Management

The record serves as objective documentation of all phases of treatment, including diagnosis and assessment, laboratory testing, and treatments used and the patient’s consent for them.

 

"The paper or electronic patient health record serves two major purposes: communicating information both within and outside the practice/clinic setting about a patient; and creating a written history of patient care in the event of later questions or challenges. The record serves as objective documentation of all phases of treatment, including diagnosis and assessment, laboratory testing, and treatments used and the patient’s consent for them." - Read More.