What type of document details the resident's medical and treatment history?

What type of document details the resident's medical and treatment history?

• A. Transfer documentation
• B. Medical record
• C. Discharge summary
• D. Insurance claim form

Answer: (B)

The correct choice is the medical record, which is a comprehensive document that contains a resident's complete medical and treatment history. This record includes critical information such as past and current medical diagnoses, treatment plans, medications administered, progress notes from healthcare providers, and any other relevant health information pertinent to the individual's care. The medical record serves as a central repository for a resident’s health history and is essential for continuity of care, allowing different healthcare providers to access crucial information related to the resident's health status and treatment. It is a legally protected document that ensures accuracy and confidentiality regarding the resident's health information. In contrast, transfer documentation reflects the information necessary for transferring a patient from one facility to another but does not contain the complete medical history. The discharge summary provides a summary of the care provided during the stay and outlines follow-up care and instructions, while an insurance claim form primarily focuses on billing and reimbursement details rather than providing medical history or treatment specifics.

The correct choice is the medical record, which is a comprehensive document that contains a resident's complete medical and treatment history. This record includes critical information such as past and current medical diagnoses, treatment plans, medications administered, progress notes from healthcare providers, and any other relevant health information pertinent to the individual's care.

The medical record serves as a central repository for a resident’s health history and is essential for continuity of care, allowing different healthcare providers to access crucial information related to the resident's health status and treatment. It is a legally protected document that ensures accuracy and confidentiality regarding the resident's health information.

In contrast, transfer documentation reflects the information necessary for transferring a patient from one facility to another but does not contain the complete medical history. The discharge summary provides a summary of the care provided during the stay and outlines follow-up care and instructions, while an insurance claim form primarily focuses on billing and reimbursement details rather than providing medical history or treatment specifics.