The patient care report must record information that is considered confidential.
The Patient Care Report (PCR)'s primary function is to capture all care and essential patient information while also serving as a data gathering tool. It must contain, but is not limited to, record of the occurrence or incident, the patient's medical condition, treatment administered, and medical history.
The PCR paperwork is regarded a medical document and forms a permanent part of the patient's medical record. It is also regarded as a legal document in circumstances involving culpability and/or negligence. It is the foundation for all medical billing claims. All patient data is treated as private and confidential. This comprises financial, demographic, registration, and clinical information about the patient. Internal and external disclosure of patient information documented in the patient care report is protected by hospital rules and procedures, as well as state and federal regulations.
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