The medical record:
A) serves as a major communication tool but is not a legal document.
B) cannot be used to assess quality of care issues.
C) is not used to determine reimbursement claims.
D) can be used as a tool for biomedical research and provide education.

Question

Quizplus · Accepted Answer

The medical record is a clinical data archive. The medical record serves as a tool for biomedical research and provider education, collection of statistical data for government and other agencies, maintenance of compliance with external regulatory bodies, and establishment of policies and regulations for standards of care. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters.

The Medical Record