Although anyone who comes into contact with a medical record is responsible for the accuracy of his or her own entry, the office in the medical practice that is ultimately responsible for proper documentation and correct coding is: "The Physician".
Medical records refer to all the medical details that are related to medical patients.
Medical practitioners (Physicians) are trained to codify and accurately document these facts and information as they are important for proper diagnosis.
Medical records can be categorized into the format of storage; or the details they contain.
For formats of storage there is:
For the details that they contain, we have:
Medical entities are required to also keep these kinds of records.
Learn more about Medical records at;
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