What items are mandatory in a medical record? Why?
Answer:
-Owner's name
-Patient's name
-Patient's information
-SOAP
-Physical exam
-Treatments: Must include name of drug, strength, route of administration, and the initials of the administrator
-Diagnosis
-Laboratory data: Interpretation and comments regarding abnormalities
-Prognosis: Excellent, fair, guarded, or poor
-Initials of the doctors and technicians
All information is required to have a complete medical record