What are the functions of medical record?

Legal documentation: Medical records serve as legal documentation of a patient's medical history, including diagnosis, treatment, and outcomes. They provide a factual and objective account of the patient's condition and the medical care provided.

Communication: Medical records facilitate communication among healthcare professionals involved in a patient's care. They enable a seamless flow of information between doctors, nurses, specialists, and other healthcare providers, ensuring that everyone has access to the same patient information.

Quality assurance: Medical records are used for quality assurance purposes to monitor and evaluate the quality of healthcare services. They help identify areas for improvement and ensure compliance with standards and regulations.

Education and research: Medical records serve as a valuable resource for education and research. They can be used to study disease patterns, treatment outcomes, and the effectiveness of various medical interventions. Research based on medical records contributes to the advancement of medical knowledge and the development of new treatments.

Patient care planning: Medical records are essential for developing and implementing effective patient care plans. By reviewing the patient's past medical history, current symptoms, and treatment response, healthcare providers can make informed decisions about the appropriate course of care.

Financial management: Medical records are used for financial management purposes to ensure accurate billing and reimbursement for healthcare services provided.

Support for decision-making: Medical records provide valuable information for decision-making related to patient care, including treatment options, referrals to specialists, and recommendations for further testing or procedures.