practice of Medicine


Documentation in the Medical Office


  • Identify the purposes of the medical record
  • Identify subjective versus objective examples of documentation
  • Identify what type of documentation to avoid in the medical record

The medical record serves many purposes, but its primary function is to plan for patient care and provide for continuity of information about the patient's medical treatment. As a permanent record, the …

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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.