ASCP Phlebotomy Technician Certification Practice Exam 2025 - Free Phlebotomy Practice Questions and Study Guide

The term "medical record" refers to a comprehensive legal document that contains a patient's history of treatment, including diagnoses, treatments received, medications prescribed, and various other health-related information. It serves not only as a record of care provided by healthcare professionals but also as a means of communication among different providers who may be involved in a patient’s care. This document is essential for ensuring continuity of care, facilitating proper treatment, and protecting the patient's legal rights in healthcare settings.

While the term "patient chart" can be used interchangeably with "medical record", it often refers to the visual representation or organized summaries of the patient’s care in a specific clinical episode, rather than the complete legal document. A "treatment log" generally refers to a more informal record and may not capture all elements of a patient’s medical history pertinent for legal or comprehensive healthcare records. "Healthcare summary" can refer to a brief overview, typically provided for specific purposes such as transitioning to another care facility, and may not encompass the entirety of a patient's treatment history. Thus, "medical record" is the most accurate and encompassing term in this context.