ARRT Patient Care Practice Exam

Which of the following must be documented in a patient's medical record?

1. Diagnostic and therapeutic orders

2. Medical history

3. Informed consent

4. All of the above

The correct answer is: Medical history

The documentation of a patient's medical record is essential for providing comprehensive and continuous patient care. Each component plays a vital role in ensuring the patient's safety and the quality of care they receive. Medical history is a foundational aspect of a patient's record. It encompasses past medical conditions, surgeries, allergies, medications, and family health history, which are crucial for understanding the patient's overall health, informing current treatment decisions, and anticipating potential complications. Accurate and detailed medical history documentation is critical for effective diagnosis and treatment. While diagnostic and therapeutic orders as well as informed consent are undoubtedly important and must also be documented for legal and medical reasons, the question specifically concerns which must be documented, and the medical history serves as the core basis for any treatment plan or intervention made thereafter. Thus, although other elements hold significant importance in the care process, the medical history is specifically foundational and is typically the first thing reviewed during patient interactions, making it indispensable in any patient record.