what is Medical records?

Requirements for Medical Records


Medical records must state the necessity for and the extent of services provided. The following requirements may vary according to the service rendered:
• Description of what was done during the visit;
• History;
• Physical assessment;
• Chief complaint on each visit;
• Diagnostic tests and results;
• Diagnosis;
• Treatment plan, including prescriptions;
• Medications, supplies, scheduling frequency for follow-up or other
services;
• Progress reports, treatment rendered;
• The author of each (medical record) entry must be identified and must

authenticate his or her entry by signature, written initials or computer
entry;
• Dates of service; and
• Referrals to other services.

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