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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.

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