Which types of patient care information must be included in the medical record?

The key reason for including admitting diagnosis and physician's examination report in a medical record is that these elements are vital for understanding the patient's medical history and treatment plan. The admitting diagnosis provides the initial reason for the patient's visit or admission, outlining the medical issue that needs to be addressed. This foundational information is essential for any subsequent care, treatment decisions, and for other healthcare providers who may be involved in the patient's case.

The physician's examination report complements the admitting diagnosis by detailing the findings from the physician's assessment. This may include symptoms, physical examination results, and any preliminary conclusions that can guide treatment. Together, these components create a comprehensive view of the patient's condition at the time of admission, which is crucial for ensuring continuity of care and informed decision-making among healthcare providers.

While immunization records, insurance details, and scheduled follow-up appointments are important aspects of overall patient management and can be part of a medical record, they do not typically carry the same level of immediate relevance to the patient's diagnosis and treatment as the admitting diagnosis and examination report. These latter elements are foundational and specifically targeted at addressing the medical needs of the patient.