What is the primary purpose of a medical record?

The primary purpose of a medical record is to document the encounters between providers and patients. This documentation is vital because it captures the details of patient care, including diagnoses, treatment plans, medical history, and ongoing assessments. These records serve multiple roles in patient care, such as providing continuity of care by ensuring that all healthcare providers have access to a patient's health information. This comprehensive documentation is crucial for delivering effective and safe medical care.

While the medical record can certainly assist insurance companies by providing necessary information for claims and audits, its main focus is on the provider-patient relationship and the medical care delivered. Additionally, while medical records can serve as legal documents in court, that is a secondary function rather than the primary purpose. Similarly, collecting information for future patient use is also a benefit of the medical record, but it is not the main goal of its establishment. The cornerstone of a medical record lies in the documentation of the clinical interactions that occur during healthcare delivery.