Industries & Professions /
Medical Record Technicians
A patient's medical record consists of all relevant information and observations of any health care workers who have dealt with the patient. It may contain, for example, several diagnoses, X-ray and laboratory reports, electrocardiogram tracings, test results, and drugs prescribed. This summary of the patient's medical history is very important to the physician in making speedy and correct decisions about care. Later, information from the record is often needed in authenticating legal forms and insurance claims. The medical record documents the adequacy and appropriateness of the care received by the patient and is the basis of any investigation when the care is questioned in any way.