Medical record notes, (also called chart notes, outpatient notes, or progress notes) are the formal or informal notes taken by the physician when he or she meets with or examines a patient in the office, clinic, acute care center, or emergency department. These notes are part of the patient’s permanent medical record and are vital to effective patient care. Although medical records are used mainly to assist the physician with care of the patient, they can be reviewed by attorneys, other physicians, insurance companies, or the court. It is essential that the medical records are neat, accurate, and complete
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