What Should Be Included In a Medical Record

December 7, 2020

Some people are surprised to learn that different medical providers don’t necessarily all have access to the same medical records. Although this is starting to improve with the advent of electronic health records, there is still a marked disconnect between all the various health care providers that people see. From the primary care physician, to specialists, to urgent care, and hospital stays, it’s rare that all relevant medical information is available to any one doctor.

It’s important for people to know their own health history, and take responsibility for sharing relevant information with healthcare providers, especially during emergencies. Communicating the right information at the right time can make an enormous difference in the outcome of a medical event. It’s also important to ask, “What is my right to access medical records?” Sometimes it can be difficult to access your patient record because of protected health information, so knowing your rights is imperative.

Once you compile your personal medical record, keep several copies on hand, and be sure a backup is available in case of a fire or natural disaster. Alternatively, use a secure, accessible, easily organized online format to store medical records online, such as Pillar. Here's everything that should be on your medical record.

The Basics: What Information Must All Patient Records Contain?

What should be included in a medical record will depend on your unique medical history, and how much detail you feel compelled to keep. It can also depend on how long doctors have to keep medical records. A personal medical record may be very extensive, or rather slim. Your health record is about you. But at the absolute basic, your medical records should contain your:

  • Name (and previous names)
  • Date of birth
  • Blood type
  • Allergies (including drug, food and environmental)
  • Details about any current or chronic medical conditions
  • Date of diagnosis, or the approximate length of time for any conditions
  • Current treatments
  • Details descriptions of past (even unsuccessful) treatments can also be helpful
  • List of dates and basic information about doctor’s visits, procedures, surgeries or hospitalizations and lab work or health screening over the last year.
  • Dates and information about major illnesses, accidents, surgeries or hospitalizations you have had. (Listing who treated you and where is helpful)
  • Information about any implants you may have, including pacemaker, or any metal parts in your body.
  • List of medications. Include all prescription and over the counter medications, as well as vitamins and supplements. (These substances can have interactions with other medications so it’s important for your health care provider to have the whole picture.)

For each medication or supplement you should include:

  • Dosage
  • How frequently you take it
  • How long you have been taking it
  • The name of the health care provider who prescribed it
  • Why you take it

And finally, the name and contact information for your:

  • Primary care physician
  • Specialists or mental health providers
  • An emergency contact and at least one secondary contact, in case the primary can’t be reached

Completing the Picture: More Useful Information for a Complete Medical Record

If you want to keep track of your comprehensive medical history, your medical record should also include:

  • Social Security Number
  • Medicare / health insurance information (company name, policy number, and contact information)
  • Insurance forms relating to medical treatments can be helpful
  • Each health care provider name, their contact information, and what they do for you
  • Primary care physician
  • A list of specialists
  • Dentist
  • Eye doctor
  • Mental health providers or social workers
  • Physical therapists
  • Additional caregivers
  • Pharmacy name, phone number, and address

Your Medication History

In addition to the current list of medications and treatments you're on, it can also be helpful to keep a list of key medications you’ve taken in the past for record keeping purposes. Include poor reactions you’ve had to medications in the past. List the name of the drug, why your healthcare provider prescribed it, and how you reacted (caused dizziness, itching, etc), along with the dates, if possible.

  • Logs of blood pressures, blood sugars, or other vital signs or tests you take regularly. Include the time of day your reading was taken, if you can. Some people use apps or software to track these things if taken frequently. For record keeping, list passwords, and access information securely in your medical record.
  • List of visits to doctors, hospitals and other healthcare providers, organized by date. Make a note of any treatment from each doctor and clinic. Include visit summaries and notes, if possible
  • List of bloodwork and other lab tests with dates and locations (x-rays, MRIs, bone density scans, mammograms, prostate screenings, etc). Include the results, if possible
  • Mental health and counseling records
  • Vision and dental records
  • Notes about lifestyle habits (smoking, drinking, sleep, exercise, diet)

Your medical record is also about your family history. Specify whether any siblings, parents or grandparents have had any of the following:

  • Cancer (specify which types)
  • Heart disease
  • Diabetes (specify type 1 or 2)
  • Mental health conditions, including depression
  • High blood pressure
  • High cholesterol
  • Other major health conditions

Additional Legal Documents for Your Medical Records

If you have any of the following legal documents, make sure they are up to date in your current medical record:

  • Advance directive (also known as a living will)
  • DNR / POLST or other medical directives
  • Medical / Financial Power of Attorney paperwork
  • Permission forms for releasing medical information (HIPAA / Privacy forms)
  • Organ donor documents
  • Vaccination records
  • Pharmacy informational printouts for each of your medications

What Should Not be Included in a Patient Medical Record?

There aren’t any hard and fast rules regarding what has to be included in medical records, at least as far as compiling personal health records is concerned. Medical records vary per individual. Some are fairly basic, while others will be full of detailed information. This has to do with how many health problems the person has, as well as how detailed they choose to be.

Treatment details and medical history information can be extremely helpful – but only if they’re organized. If the medical record is packed with information, but it’s too unorganized to find what you need in a timely manner, it's not actually that useful. 

Besides being organized, it is very important that a medical record be both portable and secure. The secure online document management system Pillar allows users to transform their information into an easy-to-use electronic medical record so they can easily access specific details from any online device, even while sitting in the doctor’s office or emergency room.

Frequently Asked Questions

What medical records should I keep?

At a minimum, you should keep a few printed pages with your:

  • Name
  • Date of birth
  • Blood type
  • Key medical provider(s)
  • Allergies
  • Current drug list
  • Current diagnoses or conditions
  • and emergency contact information

Beyond that, it’s a good idea to keep a list of major illnesses, accidents, surgeries and hospitalizations, and one year’s worth of doctor’s visit notes, hospital discharge summaries, lab test results. It can also be beneficial to keep billing records. Keeping further details can be very helpful, especially for individuals with complex medical conditions, or multiple health care providers.

Can you clear your medical record?

Generally, there's no way for a person to have something deleted from an official medical record. If there is an error, HIPAA (federal law regarding privacy and portability of health records) allows for people to request an amendment – an additional record which corrects the mistake

How can I remove something from my medical records?

It’s a good idea to review your medical records, for example by viewing them through the online patient portal available through most medical providers. If you find an error that may impact billing records or future medical care, you should write a clear, concise letter to the healthcare provider identifying exactly what and where the error is, and what you believe would correct it. The provider must then either accept or deny the correction in a timely manner, generally within 60 days.

Is my blood type in my medical records?

Yes. Blood type should be included in a personal medical record.

Where to Begin a Personal Medical Record

For people with complex medical histories, it can seem overwhelming to tackle a task of this magnitude. Thinking of what should be included in a medical record can feel daunting. It’s okay to start compiling a little at a time. Perhaps start by asking the question, “how do I get my medical records?” When it comes to your electronic health record, begin with the basics and add to it as changes occur. If you want to start filling in blanks from the past, you can check online patient portals or contact providers for copies of past medical records. Insurance companies can also be a good source of dates and other information. Once you have been able to gather pieces of your medical chart, spend some time learning how to organize medical records. It’s worth going through the trouble because taking responsibility for your own health information can make a big difference in the outcome of future medical care – which can translate to quality of life.

The most important things to remember about a personal medical record is to keep it organized, accessible, portable, and secure. Start your free 14-day trial and store your entire medical  and history in one safe, secure online vault to take ownership of your health whenever you need it.

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