One’s health information – or medical records – not only provides the base for planning care and treatment but is a legal document that verifies care and services and treatment covered by insurance and is an effective way to communicate this information to providers. According to the American Health Information Management Association, the specific content depends on the type of health care a person has received, but typically includes the following:
An Identification Sheet listing your name, address, telephone number, insurance type, and policy number plus a “problem list” of significant illnesses and surgeries you have experienced and person to notify in case of an emergency.
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A Medication Record or list of medicines that have been prescribed or given to you plus any medication or other allergies you may have.
A History and Physical document describing any major illnesses and surgeries, significant family history of disease, health habits and current medications – plus a documentation of your height, weight, blood pressure, pulse, respiration and any other symptoms.
Progress Notes made by doctors, nurses, therapists, and social workers that reflect your response to treatment and their observations and plans for continued treatment.
Consultation notes or an opinion about your condition made by a physician other than your primary care doctor. It may look like a letter or be recorded on a specific consultation form.
Physician’s Orders contain directions to other members of the health care team regarding medications, tests, diet, and treatments.
Imaging and X-ray Reports that describe X-ray results, mammograms, ultrasounds, or scans (the actual films are usually maintained in the radiology or imaging departments).
Lab Reports that 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. (Surprisingly, your health record does not usually contain your blood type since blood typing is not part of routine lab work).
An Immunization Record documenting immunizations given for diseases such as polio, diphtheria, pertussis, tetanus, measles, mumps and rubella, polio, and influenza.
Correspondence exchanged between you and your health care provider, inquiries made by your insurance company about the care you received, and copies of forms the physician has completed and sent at your request.
Authorization Forms including copies of consents for admission, treatment, surgery, and release of information.
Documents regarding hospital stays or surgery, such as an Operative Report describing surgery performed and the names of surgeons and assistants; Anesthesia Report documenting preoperative medication, anesthesia given, and responses to the anesthesia during the surgery; Pathology Report describing tissue removed during an operation (if any) and diagnosis based on examination of that tissue; Recovery Room Record documenting your condition when you leave the operating room until you arrive at the nursing unit; Graphic Sheet or graph used to plot your temperature, pulse, respiration, and blood pressure over some period of time; Discharge Summary of a hospital stay including reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care.
Reports from other services such as emergency room, intensive care unit, a physical therapist, or home health nurse.
According to the AHIMA, patients can save money by only asking for recent information rather than the entire chart or requesting specific documents within their records such as problem lists, medication and allergies lists, immunization records and most recent history and physical, consultations, and operative reports, pathology reports, and discharge summaries from hospitalizations.
While it isn’t necessary to get copies of your record every time you visit your doctor, the AHIMA suggests getting copies of operative reports, discharge summaries, and significant tests from any hospital visit, and incorporating into this file the name and phone number of one’s personal physician, dentist, optometrist, and pharmacist, eyeglass prescription and dental information (dentures, bridges, etc.) and copies of advance directives and organ donor authorization.
