Continuity and Quality in Medical Care

The medical record must “tell the story” of the patient
as determined by the physician in the circumstances
in which he or she saw the patient. The components
necessary to tell the story are set out in detail below.
The record is not just a personal memory aid for the
individual physician who creates it. It must allow
other health care providers to read quickly and understand
the patient’s past and current health concerns.
It is not expected, however, that all patients will
always be able to read and understand their medical
records. Medical records may contain abbreviations
and terminology unique to the health care professions.