The medical assistant plays a major role in writing and maintaining patient records. These records document the evaluation and treatment given to the patient. Patient records are critical to the care of the patient. Without accurate and complete patient records, medical care could easily be compromised.

• Personal information or data
• Physical and mental condition
• Medical history
• Medical care
• Medical future if the patient is referred to other physicians

In this chapter you will learn how to carefully manage the records of the patient. You will understand that if the medical care is not documented, in a legal sense, the medical care did not occur at all.