A medical record (MR) is the chronological documentation of medical treatment and other
health care delivered to a patient by professional members of the health care team. It is an accurate,
prompt recording of the team’s observations about the patient, the patient’s medical progress, and the
results of treatment. It is a means of communication among health professionals, a legal document,
and a tool for medical research and training. It is also the primary means of evaluating the quality and
appropriateness of medical care rendered, as well as a source document for statistical use in research,
planning, and budgeting. Finally, it is the original-source document for financial activity involving
patient care.