A chronological written account of a patient examination and treatment that includes the patient medical history and complaints is called what?

• A. Medical Record
• B. Nursing Notes
• C. Care Plan
• D. History and Exam Log

Answer: (A)

The item tests knowing the term for a complete, dated record of a patient’s health information and care. The medical record is the official, comprehensive document that includes the patient’s medical history, current complaints, exam findings, diagnoses, treatments, and outcomes, organized in chronological order so that anyone reviewing it can understand the patient’s health course. Nursing notes focus mainly on nursing observations and care, not the full medical history and treatment record. A care plan describes intended interventions and goals rather than the complete history of examinations and treatments. History and exam log isn’t the standard term used for the full, ongoing record of a patient’s medical history and care.