Medical records reports

What is the purpose of medical records?

• To provide a written account of the health care for a patient.

• To provide conformation of a patients appointments.

• To provide a documentation of medical services for insurance purposes.

• To obtain consent from a patient prior to treatment.

Computerized medical records

• Pose problems of confidentiality

• Make record maintenance and retrieval more efficient

• Should be accessed on a need to know basis

• All of the above

What rights do patients have regarding their medical records?

• None

• To view and make copies

• Rights to have records destroyed

• Rights to view only

A medical record is a legal document that may be ordered by the court to be available during a malpractice case

• True

• False

The medical record must include information about patient care such as

• Admitting diagnosis

• Physician examination report and documentation of complications.

• Discharge summary and follow up care

• All of the answers are true

What is a disadvantages of paper records?

• They can be used by only one person at a time.

• They are old and out of date

• They take a long time to mail

To protect patient confidentiality medical records can be released

• To an attorney

• To a judge

• Only with the patient written consent

• To insurance companies