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Medical Records 101

What Should Be In My Medical Record?

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We cannot overemphasize the importance of having all your medical records in one place. The more information about you and your health history a doctor has, the better he or she is able to treat you.

The medical records of a person with a serious health condition should at least include the following:

  • Details of all treatments you undergo including:
    • Conventional U.S. medicine and complementary or alternative treatments
    • The specific treatment
    • The period of time you underwent the treatment (including number of days in hospital if you were admitted to the hospital)
    • Your condition at the start and end of treatment
    • Your reaction to the treatments, including any problems you encountered
  • Medications you took and/or continue to take
  • Lab reports
  • Pathology reports
  • CT ScanMRI, PET ScanX-ray and other scan reports

For additional details, see below.

NOTE: If you work, your medical records should also include how your condition and/or treatment(s) affect your ability to work, as well as any depression or other emotions you experience that could ultimately make you unable to continue to work. These entries become persuasive proof in the event you ever want to file for disability under Social Security Disability Insurance or otherwise.

General Information That Should Be In Your Medical Record: According to American Health Information Management Association, the following information should be contained in your file where appropriate:

  • Personal identification, which is usually your Social Security number. It may be a name or number assigned to you by the doctor or facility
  • Who to notify in case of an emergency
  • Name and phone number of your primary care physician, specialists, dentist, optometrist, and pharmacist
  • A list of all your current medications
  • Your immunization record
  • Allergies including those to any medications
  • Important events and dates in your personal history
  • Important events and dates in your family's history, especially your parents, blood aunts or uncles, and your brothers and sisters
  • Important test results such as X-rays and EKG's
  • Eyeglass prescription
  • Dental information (dentures, bridges, etc.)
  • Copies of Living Will, Healthcare Power of Attorney and Do Not Resuscitate Order
  • Health insurance information

Specific Documents That Should Be In Your Medical Records

According to the American Health Information Management Association whose members are the keepers of the nation's health records, the following document descriptions are those that are common to most medical records. The list also includes the additional documents that accompany hospitalization and surgery.

  • Problem List is a list of significant illnesses and surgeries you have experienced.
  • Identification Sheet is often a form originated at the time of registration. The form lists your name, medication record with a list of medicines that have been prescribed, and any medication allergies.
  • History and Physical is a document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits and current medications. In addition, it usually documents your height, weight, blood pressure, pulse, respiration, and any symptoms you have described.
  • Progress Notes are notes made by the doctors, nurses, therapists, and social workers caring for you. These notes will reflect your response to treatment and their observation and plans for continued care.
  • Consultation is an opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your doctor would like the advice and counsel of another doctor. At other times, a consultation occurs when you request a second opinion. A consultation may look like a letter or may be recorded on a specific consultation form.
  • Doctor's Orders are contained in a document with your doctor's directions to other members of the health care team regarding your medications, tests, diet and treatments.
  • Imaging and X-ray Reports are documents describing x-ray results, mammograms, ultrasounds, or scans. The actual films are usually maintained in the radiology or imaging departments of the health facility in which the tests occur.
  • Electrocardiogram (ECG, EKG) is the cardiologist's interpretation of graphic tracings that represent the electrical changes in the heart as it beats.
  • Lab Reports describe the results of tests conducted on body fluids and waste products such as blood, sputum, and urine. Common examples would include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work. When you donate blood, the blood bank usually provides you with a card indicating your blood type. Should you lose your card, most blood banks maintain a record and can tell you your blood type.
  • Immunization Record is a form documenting immunizations you've received for diseases such as polio, diphtheria, tetanus, measles, mumps, rubella, and influenza. Because physicians move and retire, and the information is required prior to entry into kindergarten, first grade, and college, parents should maintain a copy of their children's immunization records with other important papers.
  • Correspondence is letters exchanged between you and your health care provider, inquiries made by your insurance company about the care you received, and copies of forms the doctor has completed and sent at your request.
  • Authorization Forms include copies of each "release of information" you signed as well as any "consent" you executed for admission to a medical facility, or before treatment or surgery.
  • A release of information is a document you must sign before your doctor or medical facility may release any information about your health condition except as may be required by law.
  • A consent is a document you sign before any procedure or treatment may be started on you in which you agree to that procedure or treatment.

Hospital Records That  Should Be In Your File

If you have spent time in a hospital, the following should be in your file, as appropriate:

  • Operative Report: A document describing surgery performed, and includes the names of surgeons and assistants.
  • Anesthesia Report: A form documenting preoperative medication, anesthesia given, and your responses to the anesthesia during the surgery.
  • Pathology Report: Describes tissue removed during an operation (if any). A pathology report also gives a diagnosis based on examination of that tissue.
  • Recovery Room Record: A form documenting your condition from the time when you leave the operating room until you arrive on the nursing unit.
  • Graphic Sheet: Generally is a graph used to plot your temperature, pulse, respiration, and blood pressure over a period of time.
  • Discharge Summary: A concise summary of your stay including:
    • The reason for admission
    • Significant findings from tests
    • Procedures performed
    • Therapies provided 
    • Response to treatment 
    • Condition at time of discharge
    • Instructions for post-discharge medications, activity, diet, and follow-up care.

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