Explanation should include medical records as
- legal and binding documents, which can be subpoenaed in court
- an account of events that occur during a patient’s care
- determination of payments by insurance companies
- intergroup language communication documents.
Process/Skill Questions
- What is the importance of keeping accurate and complete records in all branches of healthcare?
- What are the possible effects of incomplete or absent documentation?
- What resources and tools are available to manage medical information?
- What barriers might a patient encounter with an electronic medical record?
- What benefits might a patient receive from the use of electronic medical records?
- What are the consequences of failing to document the administration of medications?
- How would the medical record be useful in the investigation of a medical error?