Page 5 - Law And Rules Regarding Medical Record
P. 5
CikguOnline
CikguOnline
Medical Records
• Documented information about the health of an identifiable individual recorded by a
practitioner or other healthcare professional, either personally or at his or her
instructions.
• It should contain sufficient information
➢ to identify the patient, support the diagnosis based on history, physical
examination and investigations, justify the professional management given, record
the course and results thereof, and ensure the continuity of care provided by
practitioners and other healthcare workers to that particular patient.
