What information does my medical record contain?

What information does my medical record contain?

Your medical record contains a whole host of information about you. Some of it's demographic, and that means personal information about who you are, the type of insurance, the name of your primary care doctor, your address, phone numbers, and things of that nature. Another section of the medical record has administrative information in it. For example, if you're in a hospital, the forms that show that you agreed to be admitted and treated, documents related to financial arrangements, authorizations for treatment, etc. Another section, the major section of the medical record, has reports about your care, the history and physical examination, your medical and nursing care plans that have been developed, charting and notations that have been made about your progress during your hospital stay, instructions and orders given by your physicians, medications that have been ordered and given and when they have been given, results of diagnostic tests that were ordered for you, observations of your condition and progress made by the physicians, the nurses, and other health care providers, your diagnosis and treatment. All of these elements make up your permanent medical record, the history of your stay or your history of your relationship with your physician.