What records must be kept for patient care?

• A. Only billing records.
• B. All records must be public.
• C. Records are optional.
• D. Records documenting evaluation, diagnosis, treatment, consent, procedures, and billing, maintained securely and available for patients or audits.

Answer: (D)

Records kept for patient care should be comprehensive, documenting the entire care process—from the initial evaluation and diagnosis through the treatment plan, any consent obtained, procedures performed, and the billing related to care. Keeping these records securely protects patient privacy and ensures that anyone involved in the patient’s care has the information needed to make informed decisions, maintain continuity of care, and respond appropriately to questions or concerns. These records also provide a clear, auditable account of what was done and why, which supports quality review, regulatory compliance, and eventual audits. Patients have the right to access their own records, and secure handling meets professional and legal standards for confidentiality. Options that mention only billing omit essential clinical details; suggesting records are public violates privacy; calling records optional would undermine safety, accountability, and continuity of care.