The Key Communication Tool (Spring 1995)

Spring 1995 page 12-end The Key Communication Tool The medical record is an important document for persons involved in treating a patient or in communicating information about a patient's condition or treatment to appropriate third parties. The medical record is a source document of information and data for a wide variety of purposes, most importantly for patient care, but also for use as a legal document and medical research. These principles apply whether the record is an inpatient document or is office based. Technological advances in health care have affected the medical record. New methods of diagnostic testing and...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This Spring 1995 article explains the role of the medical record in patient care, communication among providers, legal and regulatory needs, claims support, and coding workflows. It is aimed at physicians, office staff, and others who review records for documentation quality and coding support, with emphasis on broad documentation principles and the importance of CPT-related familiarity.

Why This Topic Matters

A well-structured medical record affects care continuity, record integrity, reimbursement support, and the ability to code services accurately. The article helps readers understand why documentation quality matters across clinical, administrative, and compliance settings.

Article Sections

  1. Spring 1995 page 12-end

    Introduces the article and frames the discussion within the cited publication context.

What You Will Learn

  • Why the medical record matters for patient care and communication
  • How documentation supports legal, administrative, and regulatory needs
  • Why complete records are important for claims and reimbursement support
  • How medical records relate to diagnosis and procedure coding workflows
  • The general role of CPT familiarity for those reviewing records

Who Should Read This

  • Physicians
  • Medical office staff
  • Coders
  • Billing and claims personnel
  • Health care administrators

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