Components of a Medical Record

Medical Records

Have you ever requested a family member’s medical record or your own from a facility only to find that nothing makes sense to you? A medical record can be complex and have many parts to it which can be overwhelming if you are not familiar with reading the records.  In looking at the record, there are ten components that show your past and present medical history, along with billing that is sent to the insurance. This breakdown of each part is to help you understand what information is included in your record along with an explanation for a better understanding of each item found in your record.  

Do you ever wonder what makes up Medical Records, and what different types your facility may use? 

Components of a Medical Record

Medical Records are made up of ten components. These components will help current and future medical professionals gain an insight of the wellness and health of their patient, in conjunction with information to develop other ways to accomplish patient care. This information can help develop other ways to accomplish better patient care. This information is covered under HIPAA. 

The ten main components of a Medical Record are:

1. Identification Information 

Included in this portion of the record, the identification information is date of birth, name, marital status, social security number and other pertinent information to establish a history for the patient.  

2. Medical History

A medical history is used to acknowledge a person’s past or current health such as: 

  • Allergies 
  • Treatments 
  • Medical Care 
  • Diagnoses

3. Medication Information 

This is also referred to as Drug therapy, which is an important part of the medical record. In this section it will show your current and past medications. Your medical professionals will review this list when deciding the medications you should take, so that you don’t have any adverse reactions.  Medication history includes herbal remedies, illegal substances, and OTC (Over the Counter) medicines. To gain this information it can be obtained from the patient or via prescriptions from past medical professionals on file. Your pharmacy can also provide you with a list of your past and current prescribed medications.  

4. Family History 

As defined by the National Cancer Institute, family medical history is “a record of the relationships among family members along with their medical histories. This includes current and past illnesses. A family medical history may show a pattern of certain diseases in a family.” Family History plays a significant role in a patient’s health. Health concerns can be genetic or hereditary, which can be worrisome, but should be documented. 

5. Treatment History 

The treatment history encompasses all treatments and test results that a patient has encountered or shared with their medical professional. Some examples include:  

  • Chief Complaints 
  • History of Present Illness 
  • Vital Signs 
  • Physical Examination 
  • Surgical History 
  • Obstetric History 
  • Medical Allergies 
  • Family History 
  • Immunization History 
  • Habits Including Diet, Alcohol Intake, Exercise, Drug Use/Abuse, Smoking etc. 
  • Developmental History 

6. Medical Directives 

Per the definition from Mayo Clinic, “A medical or health care power of attorney is a type of advance directive in which you name a person to make decisions for you when you are unable to do so. In some states, this directive may also be called a durable power of attorney for health care or a health care proxy.” Different types of advanced directives are a Living Will, showing who is your healthcare proxy that has the legal rights to make medical decisions for you when you are unable to do so. It is only used at the end of life if a person is terminally ill or permanently unconscious. Here it will describe the types of medical treatment the patient would like to receive in the current situation. Another is Durable Power of Attorney for Health Care/Medical Power of Attorney. Here this will define the person who is the proxy to make all your health care decisions if you are unable to do so. These are just a few medical directives that are found within the medical record. Do you know what your medical directives should be? 

7. Diagnostic Results 

Diagnostics are prescribed test used to help diagnose a health condition. Diagnostic can either be invasive or noninvasive, which may include laboratory tests and radiological imaging studies. 

Laboratory results included here are related to cells, tissues, or body fluids.  

Radiology study impressions such as X-Ray and imaging through scans, mammograms, and ultrasounds. 

8. Consent Forms 

Prior to a medical procedure or admission to a hospital, a patient has the right to make informed decisions about their care at that moment. Information includes, but not limited to: 

  • Diagnosis 
  • Recovery Chances 
  • Recommended Treatment 
  • Benefits and Risks of the Treatment 
  • Success probability if Treatment is Taken 
  • Length of Recovery Time and Challenges 

9. Progress Notes 

Progress Notes are an important tool for multiple medical professionals, as it serves as a communication tool for them to know the status and achievements during the course of the patient’s hospital stay or outpatient care.  

Information can include: 

  • Bowel and Bladder Functions 
  • Observation of the Mental and Physical Condition of the Patient 
  • Sudden Changes Taking Place 
  • Food Intake 
  • Vital Signs 
  • Physical Therapy 

10. Financial Information 

In the financial information section of your medical records, it will let you know the services that were done and the cost of each service. Here it will also show what has been billed to your insurance. Information that is included, but not limited to: 

  • Subscriber Name 
  • Policy Number 
  • Name, Phone Number, and Address of Insurance Payer 
  • Relationship of the Patient to the One Insured 
  • Phone Number, Address and Name of Responsible Party 
  • Occupation, Employer Phone Number and Employer of the Responsible Party 

Three Primary Formats of Medical records 

The above records can be found in three primary formats: Electronic (EMR), Paper and Hybrid (HHR). 

According to Nextgen Healthcare, “The term Electronic Medical Record (EMR) is best understood as a digital version of a patient’s chart. It contains the patient’s medical and treatment history from one practice. Usually, this digital record stays in the doctor’s office and does not get shared. If a patient switches doctors, his or her EMR is unlikely to follow. This form of a medical record is considered the equivalent of paper records within the healthcare facility.” 

Paper Chart uses physical paper, films, and discs to make up a patient’s health record. With this form of a record, it is easier to be lost or misplaced, this is not good for the patient down the line when it comes to their health. Another is a security issue. If a paper chart is left out, there is a chance that someone could read the chart and access any information. 

According to TechTarget, “A Hybrid Health Record (HHR) is documentation of an individual’s health information that is tracked in multiple formats and stored in multiple places.” Today, the majority of health records in the United States are considered to be hybrid. This does make it hard to find needed records if a patient is going for extended care or a second opinion.  

In requesting your medical chart, due to the facility being Hybrid, there is a chance that it will take time to receive records that are stored off site. Due to having to go off site, there is a chance that the facility that you are requesting from may charge extra due to the time spent looking for the off site records.

Reading a record can take time to get used to. We at R&G hope that this assists in an understanding of the medical chart that you have received from a facility. If there are parts of the medical chart that you are not understanding, reach out to us and our team will assist you, to the best of our ability, in helping you understand your medical history.

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