Section 441.200 - Medical record

441.200 Medical record. A record kept on patients which properly contains sufficient information to identify the patient clearly, to justify his/her diagnosis and treatment, and to document the results accurately. The purposes of the record are to serve as the basis for planning and continuity of patient care; provide a means of communication among physicians and any professional contributing to the patient's care; furnish documentary evidence of the patient's course of illness and treatment; serve as a basis for review, study and evaluation; serve in protecting the legal interests of the patient, hospital and responsible practitioner; and provide data for use in research and education. Medical records and their contents are not usually available to the patient himself. The content of the record is usually confidential. Each different provider in a community caring for a given patient usually keeps an independent record of that care.
 

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