What information must be included in a patient’s medical record to support a diagnosis?

To support a diagnosis in a patient’s medical record, it is crucial to include detailed notes on symptoms and evaluations. This information provides a comprehensive understanding of the patient's condition, documenting the clinical observations, findings from physical examinations, test results, and any relevant histories that contribute to the diagnosis.

The thoroughness of symptom descriptions and evaluations ensures that healthcare providers can communicate effectively about the patient's situation and aids in continuity of care. Such detailed records are also essential for meeting regulatory requirements and for use in scenarios like audits or insurance claims, where substantiation of a diagnosis is necessary for appropriate reimbursement and for maintaining compliance with medical standards.

Other options, while they may seem relevant, do not contain the essential clinical detail required for supporting a diagnosis. Insurance information, treatment dates, or general notes do not provide the context or clinical basis for understanding a patient's medical condition. Therefore, they would not satisfy the criteria needed to substantiate a diagnosis in a medical record.