What is the minimum information that patient records must include?

The minimum information that patient records must include centers around the clinical aspects of patient care, making the evaluation of objective findings crucial. This information is foundational for healthcare providers, allowing them to assess the patient's condition accurately, develop appropriate treatment plans, and monitor progress over time.

When documenting an evaluation, objective findings often encompass measurable data gathered through assessments and tests, such as range of motion, strength, and function. This documentation is essential not only for providing quality care but also for legal and liability purposes, as it supports the decisions made in the course of treatment.

In contrast, while social history, emergency contact information, and financial information can be valuable for comprehensive patient care and operational needs, they do not represent the core clinical data necessary for patient management. Therefore, the evaluation of objective findings is rightly identified as the essential minimum information required in patient records.