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The medical record is a legal document that will almost certainly be examined by other parties, often as part of a court proceeding. It is vital that the information be recorded accurately, completely, and legibly. The medical record must include the history, the physical examination, and laboratory and imaging results. The results of the medical evaluation must be summarized carefully and in unambiguous language. For more information about documentation, see LEGAL ISSUES: Medical Records.

The medical record should document objective findings and diagnoses based on a reasonable degree of medical certainty. Provide further opinions or discussion beyond the recorded assessment in the form of letters, affidavits, or testimony. In most situations, the results of diagnostic and forensic tests are incomplete prior to the writing of the record. Therefore, document initial impressions and send a summary letter to appropriate law enforcement or social services professionals at a later date. When there is a normal examination, explain why the examination may be normal.

Key Concepts
line spacer Documenting the History

Documenting the Findings

  • Documenting the physical examination
  • Documenting laboratory results and imaging
Documenting the Diagnosis
  • Suggested wording for documentation of a diagnosis
Documenting Other Information

Photographic Documentation

  • Consent and cooperation
  • Photographic equipment
  • Taking good photographs
Coding for Billing

Additional Resources

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Documentation: Overview  Documentation: Documenting the History  Documentation: Documenting the Findings  Documentation: Documenting the Diagnosis  Documentation: Documenting Other Information  Documentation: Photographic Documentation  Documentation: Coding for Billing  Documentation: Additional Resources 

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