What must patient records be, according to standards?

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Patient records must be legible and contain sufficient information to serve their purpose effectively. This is critical because legibility ensures that all healthcare providers involved in the patient's care can read and understand the records without confusion, minimizing the risk of errors in diagnosis or treatment. Furthermore, having sufficient information is essential to provide a complete picture of the patient's health history, treatment decisions, and progress, which supports continuity of care.

In the context of patient care, it's important that these records provide enough context for other professionals to make informed decisions about the patient’s treatment. If records are not legible or lack adequate details, this can lead to misunderstandings, miscommunications, and potential harm to the patient.

While other factors like confidentiality and proper filing are important, the primary focus of this standard centers on legibility and comprehensiveness of information, ensuring that the purpose of the record – to support clinical decision-making and patient safety – is upheld effectively.

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