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what all goes in a patient medical record

Posted by ngentry

Answers (2)
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It generally contains all your demographic information such as name, birthday, address and insurance status.  All insurance information will be there if you have insurance.  The most important of the above information is your name and birthday (and ideally a SS#).  These pieces of info are used to identify that a particular piece of health information indeed belongs to you.  Anytime your health information is discussed, you should be asked to provide this information as protection.

The remainder of the medical record will contain the notes, assessment and interventions from each Doctor visit.  If you had a visit with a specialist, the notes from that Dr should be included in you primary doctors record for you.  This allows you primary doctor to better coordinate your care.  The specialist will usually send a letter to the referring physician with a summary of their findings. If you see a specialist without a referral from your primary physician, it is best if you provide the resulting information back to your doctor or ask the specialist to send results to your doctor. There should be lists of your medications, your medical, social  and family history.  Lab orders and results as well as any other tests and the resulting interpretations of those tests.  Your allergies - this is for your protection so as to not order an intervention that may cause a reaction.  Any hospital records (or at least a summary of the hospital stay) should be included.

These are the basics of a "medical record".  It is important for this record to be complete and comprehensive.  It is your best interest that your physician have all available information so as to provide you with the most appropriate decision-making for your health.  Having all this information located with one central physician (or other care provided) is the basis for the concept of a "Medical Home".  This allows for a central point of care which reduces duplication and therefore is more cost-effective.

I agree with Alice and also suggest that if you ever have any questions to speak with your physician or other provider and possibly review your record with them.

Many medical records are still in paper form, but we are moving towards electronic health records and some of these include information that is contributed by the patient in their personal health record.  This information can include some of the information Alice mentioned, as well as, data from home monitoring devices.

NOTICE: The information provided on this site is not a substitute for professional medical advice, diagnosis, or treatment. Never delay or disregard seeking professional medical advice from your physician or other qualified health provider because of something you have read on Wellsphere. If you have a medical emergency, call your doctor or 911 immediately.
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