Medical Document

• A medical document is a record of each service provided to a patient by a doctor or hospital. Everything from a doctor visit to surgery is recorded on different documents to accurately maintain a record of what is being done to a patient or has been done to a patient. Each document is required to ensure that all doctors performing tests, diagnosis and services on a patient know what each other has performed or prescribed.
  
  

Medical Record

• The medical record is a complete history of the treatment received from a doctor, dentist or any other health care professional. The record also includes medications prescribed by doctors, laboratory test results, family medical history, type of work you perform and the lifestyle you maintain such as sporting activities, whether you smoke or where you commonly travel outside the United States. All medical documents on a patient are maintained in the medical records to inform doctors of past medical care.
  
  

Information

• The biggest difference between medical record and medical documents is that medical records contain all the medical documents on a patient. The medical document is only one test, one X-ray or one document concerning one treatment. Medical records are files that keep all of those tests, X-rays and treatments so every doctor that sees a patient does not perform the same treatment over and over again.
  
  

Billing

• Another difference between a medical record and a medical document is that only medical documents can be sent for billing to an insurance company. The medical record can list all the documents, but only the services conducted on a patient can be sent in a bill to the patient or insurance company. The bill lists all treatments performed and a medical document is available for each treatment received by the patient. Every individual medical document is considered part of a medical record.