The medical record is the essential primary document for health care communication and data storage.

In a claim of malpractice, the medical record is prima facie evidence and may offer a defense.

The justification for coding at any level must be substantiated by the medical record documentation.

Any unauthorized use of personal health information is subject to civil and criminal liabilities.

A patient is entitled to a right of access (a copy), upon request, to their personal medical record including diagnostic reports such as laboratory results and x-rays, monitoring reports, instructions, and an accounting of charges.