Patient Record Essentials Guide

A patient record, also called a medical record or health record, is a detailed, organized collection of information about a person’s health history and medical care. It is maintained and used by health care providers and serves both as a legal document and clinical tool for diagnosis, treatment planning and tracking progress or continuity of care over time. The patient record documents the history of care and provides essential information to ensure appropriate ongoing treatment. Both state and federal laws regulate the management of patient records and the information contained within. This resource provides guidance on how to document the patient record and defines what constitutes a patient record. It also includes links to TDIC resources to support policyholders with responsible access and management of patient records.