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The Basics of a Medical Record

Posted on May 23, 2019

The Basics of a Medical Record

Medical records are crucial to the continued care for a patient because it contains all a patient’s medical information. Doctors use these records to understand a patient’s previous history, diagnosis, and treatment. Health care providers such as doctors and nurses are familiar with what is contained in a medical record. However, as a patient you may not know what a medical record contains. Let’s take a look at the basics of a medical record.

Patient Demographics

This section of the medical record contains a patient’s name, address, phone, age, and gender. Other demographics can include: date of birth, marital status, occupation, and ethnicity. This information gives your provider a general overview of who you are and identify you as a patient.

Medical History

The medical history portion of the record contains your history as it pertains to your health. This includes family medical history, past clinic and hospital visits, and medications you are taking. Your family medical history will help your doctor know which inherited diseases you are prone to get. Allergies to medications and foods are also listed in this section. If you have a history of being allergic to a particular medication, your doctor can avoid that medicine and prescribe a different one for you. Knowing your medical history, your doctor or health care provider can deliver better care for you.

Laboratory Results and Diagnostic Tests

Your medical record also has your laboratory results and any diagnostic tests or images you have had in the past. The results for the various labs and tests help your doctor determine any abnormalities in your body and assist in their diagnosis.

Diagnosis and Treatment

The past and current diagnosis and treatments used is a section of your medical record. The information on the past and current diagnosis can be used to guide therapy for your current condition. It can also be used to direct future diagnosis and treatment options.

Why do you want your medical records?

You will want copies of your medical records if you are transferring your medical care to a new provider. Your new provider should know your medical information so that they will be able to continue your care. Additionally, if you see a specialist, then sharing your medical record with them is also important. Copies of your medical record will also be needed for any medical-related lawsuits you are involved with as evidence. If you want to be prepared, you should keep copies of your medical records. You don’t want to find yourself in an emergency situation without them.

How do you obtain your medical record?

Obtaining copies of your medical record is a breeze with the help of Order Medical Records. We are experts in locating medical records and can do all the work for you. Complete the ordering process from the comfort of your own home within 5 minutes. Start today by contacting us online or by calling us at 714 559-3071!

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