Which of the following information is inappropriate to include in a patient's medical record?
A Details of the patient's clinical diagnosis
B Financial information related to the patient's treatment
C Results of laboratory investigations
D History of present illness as described by the patient
Solution
Correct Answer: Option B
- The correct answer is Option 2: Financial information related to the patient's treatment because a medical record is primarily focused on clinical and health-related information necessary for patient care.
- Financial details are administrative and billing-related and typically maintained separately to protect patient confidentiality and ensure clarity of medical data.
- Including financial information in the medical record may lead to unnecessary exposure of sensitive non-clinical data and can complicate clinical decision-making.
Reference: Medical Records and Health Information Management, 3rd Edition, Chapter 4, Page 89