What type of information must be included in a medical record?

The inclusion of patient information and clinical notes in a medical record is essential because these components serve as the foundation for a comprehensive understanding of a patient's health history and ongoing care. Patient information typically encompasses demographic data such as name, date of birth, insurance details, and medical history, all of which are vital for providing appropriate care and ensuring continuity in treatment. Clinical notes document the healthcare provider's observations, assessments, and treatment plans during each visit, offering a detailed narrative that aids in diagnosing and managing the patient's conditions effectively.

Having this complete picture helps healthcare professionals make informed decisions and communicate effectively with one another, ensuring that patients receive the best possible care. In contrast, other options focus on limited aspects of a patient's record, which would not provide a holistic view necessary for effective medical practice. For example, contact information alone lacks the clinical details needed for treatment, while diagnosis codes are important but do not replace the necessity of comprehensive clinical notes. Financial records, though relevant to the administrative side of healthcare, are not central to the medical record’s purpose of documenting the patient’s clinical history and care.