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

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