Page 17 - Hospitalists - Risks When You're the Doctor in the House (Part Two)
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SVMIC Hospitalists - Risks When You’re the Doctor in the House
The medical record is evidence of the course of a patient’s
medical evaluation or workup, treatment, and condition.
Hospitals, professional review organizations, accreditation
bodies, third‐party payers, governmental agencies, medical
licensing boards, and juries may use these records to judge
the quality of patient care. The record is documentation
of communication between the patient and all healthcare
providers and may be used by patients and their families,
government agencies, public health (CDC, CMS, etc.), other
healthcare providers, third party insurers, liability carriers,
defense attorneys, plaintiff attorneys, employers, and accrediting
bodies.
The ideal medical record contains the following:
(diagram follows on next page)
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