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Introduction

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The evolution of health records parallels advancements in medicine. The first incorporated hospital in the United States, Pennsylvania Hospital, was established in 1752. Benjamin Franklin served as the secretary for the hospital and recorded each patient's name, address, disorder, date of admission, and date of discharge. Massachusetts General Hospital in Boston has the distinction of having a complete medical record on each patient since 1821.1

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Today, technology affects all aspects of health care, and the health record is no exception. Hospitals and practitioners are moving from a paper-based record to an electronic health record. Whether paper-based or electronic, the health record is the link connecting all of health care. The health record is a valuable tool used by all entities involved in providing patient care, including practitioners, hospital, patient and family, and third-party payors.

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Part I of this book addresses the health record. In some settings, the health record is called the medical record, but the more updated term is health record. Chapter 2 provides an overview of the purpose, maintenance, and content of the health record. Chapter 3 explores some of the legal aspects of the health record, and Chapter 4 addresses the relationship between documentation in the health record and reimbursement. Chapter 5 applies the information in the previous chapters directly to physical therapy practice and gives an overview of the information the therapist needs from the health record to provide patient care.

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