ABSTRACT
This chapter provides types the documents that are included in the medical record: admission sheet, medical history, social history, physical examination form, physician orders, progress notes, laboratory reports, and diagnostic imaging information. It explains the difference between source-oriented and problem-oriented medical records. The chapter describes why electronic health records are superior to traditional paper records. It also describes the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. The medical record is the only permanent legal document that includes everything about a patient's medical history, laboratory tests, and appointments with health care professionals. There are two ways in which personal health records are organized. These are the source-oriented medical record (SOMR) and the problem-oriented medical record (POMR). Accurate medical documentation allows health care professionals to communicate with each other, utilizing up-to-date patient information. HIPAA allows providers to use health care information concerning treatment, payment, and operations.
