Abstract
Medical records play an essential role in health care, and accurate record-keeping is an important administrative function. Maintaining a well-organized, easy-to-use records management system is essential in providing good patient care. A variety of people in the primary care physician’s office have contact with patients, as well as consultants, laboratories, and hospitals. It is important that each interaction is recorded in the patient’s medical record, which may be electronic or written. Medical records must be handled safely and securely, and adhere to the privacy rules of the Health Insurance Portability and Accountability Act. Each patient’s permanent health record is formed by medical records, which include health information, insurance forms, notes, physician orders, test reports, and other data. Patient records are legal documents, and may be used in court cases, so they must contain accurate and correct information. The use of computers for electronic medical records has revolutionized the health care profession.
Published Version
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