Medical record is the chronological written document of a patient’s examination and treatment that includes the patient’s medical history, complaints, physical findings and the result of diagnostic tests, procedure, medication and therapeutic procedure. It is a powerful instrument that allows the treating physician to track the patient’s medical history.
Medical record supplies pertinent data for public health authorities in the control and prevention of diseases, promotion of health in the community.
It is a legal document and provides significant evidence in regulatory, civil, criminal or administrative matters when the patient care provided by a physician is questioned.
Medical record is the property of the health care provider and the information contained in the medical record is owned by the patient only.