Everyone has their own medical record which contains a variety of information. It is a record of a person’s health and includes information from when they were babies right through their lives. Every time a person visits a doctor, hospital, or other health facility, every aspect of that visit is recorded on their medical record. But have you ever wondered exactly what information a medical record might contain? Below is a brief outline of what you might see on your medical report.
Patient Demographics
Your medical report will contain information about you, such as:
name
address and phone number
date of birth and age
email address
sex
race
marital status
social security number
job
employer
next of kin and their contact information.
Medical History
Your medical report will contain information about any illnesses and diseases you have had in the past. It will also contain information relating to treatments, examinations, medications, and other tests you have been given. You might also see details of any immunizations you have had and details of any of your obstetric visits if this is applicable. In this part of your report, you are likely to notice a variety of alphanumeric codes known as ICD or CPT codes. According to the good folk at Find-A-Code, these codes are a universal language used within the medical industry to identify specific illnesses, diseases, treatments, tests, and medications.
Lab and Test Results
The results of any tests that you have had will be included in your medical report. This might be blood tests, urine tests, x-rays, and other imaging tests.
Family History
Family history is particularly important when it comes to making accurate diagnoses, so do not be surprised to find information about things like genetic markers and hereditary diseases that any of your family members have, or have had in the past.
Financial Information
You can expect your medical report to contain information relating to your healthcare insurance. The insurance provider’s details, policy number, and subscriber name will be included. There will also be details of your relationship to the insured person, if this is not you.
Consent and Authorization
Patients must be given as much information as possible about their medical conditions and the recommended treatments. This is to ensure that they can make informed decisions in relation to consent. You can expect a medical report to include information about:
diagnoses
chances of recovery
recommended treatments
risks and benefits of the recommended treatments
risks if patient declines recommended treatment
probability of recovery if treatment is followed
challenges to recovery and expected length of time before recovery.
Progress Notes
During treatment, members of the medical team will record information about progress, which might include:
vital signs at specific intervals
food and liquid intake
bladder and bowel functions
observations relating to both physical and mental health
any sudden changes in the patient’s condition.
Accessing Your Medical Report
Although most people never see their medical record, you should be aware that you have a legal right to access it should you wish. Under the Health Insurance Portability and Accountability Act (HIPAA), you have a legal right to a copy of your report, and all medical facilities are bound by this law.
You might want your record for your personal use, or you may wish to share it with family members or other healthcare providers. You can request copies, or you can get one and then copy it should you need to. If you get an electronic copy, it is likely to be free, but should you request a paper copy you may be charged a fee.