Wisconsin CNA State Exam Vocabulary Practice

What is typically included in a medical record?

1. Only the patient's name

2. The patient's favorite color

3. A chronological account of a patient's examination and treatment

4. The patient's horoscope sign

The correct answer is: A chronological account of a patient's examination and treatment

The inclusion of a chronological account of a patient's examination and treatment in a medical record is essential for documenting the patient's health history and the care they have received. This detailed narrative allows healthcare providers to track the patient's progress, make informed decisions about future treatments, and ensure continuity of care among various providers. Such records typically encompass clinical notes, test results, medication lists, and any other relevant information that reflects the patient's medical journey. The other options do not contribute to the medical record's purpose of providing comprehensive and clinically relevant information. The patient's name is obviously important, but it alone does not fulfill the requirements of a medical record. Similarly, personal preferences like a favorite color or horoscope sign are unrelated to the medical, therapeutic, or diagnostic information that medical records are intended to contain.