Basic Parts of a Complete Medical Record

What needs to be in your medical record

Almost everyone on the planet born in a hospital has a medical record of some sort. A medical record is simply a record of a patient's health and medical history. Depending on the level or need of care a patient has, records may vary, but all medical records will contain some common information. The following is a list of the most common types of information and why it is necessary and helpful for treatment personnel to have.

1
Personal Identification Information

Medical Records
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Each medical record must have specific personal identification information, such as a social security, state, or government issued identification number in order to tie the record to the correct patient. Most records will have facility-specific identification as well, but all must have detailed personal identification.

2
Medical History

Medical Records
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Everyone has a medical history, even if they have never been to a hospital and never had their immunizations. How is this so? This is so because not having these is a part of the medical history as well. Patient medical history includes all diagnoses, medical care and treatments, allergies, and even the lack of need for medical care. This information tells medical personnel a great deal about your current symptoms, such as, whether an illness is acute or chronic, seasonal or situational. The patient’s allergy information, as well, can be a critical matter. Allergies to common or uncommon materials or medicines, even food substances, can cause problems. Up-to-date medical records can save a life in the event that the patient is unconscious or unable to speak for himself.

3
Family Medical History

Medical Records
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Information about family members' health is an important part of your medical records because some health concerns are genetic. Knowing that a distant cousin had hangnails may not be important, but knowing that the patient’s grandmother had some form of heart condition or cancer certainly is. There are many diseases that are genetic that may not show up in each generation, but the presence of those genetic markers can shed light on an illness or set of symptoms. The more family history a physician has, the more pieces to the puzzle he has.

4
Medication History

Medical Records
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What we ingest, whether it is prescribed, over the counter, herbal, or illegal, is an important piece to our medical puzzle. A medical professional needs to know about herbal, over the counter, home remedies, prescription medicines and even illegal drug use because of the way these can affect our health not only immediately, but over time. Some drugs, medicines, or other ingestible materials are water soluble, some are fat soluble; some have short half-lives, while others stay in our bodies for longer periods. Additionally, some prescription medicines are contraindicated with other remedies and can exacerbate symptoms or worse when combined with the wrong ingredients. Giving complete information here is of the utmost importance.

5
Treatment History

Medical Records
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Knowing what treatments have been given, whether they worked, and which have failed is significant information for the provider to have. This information saves time and money in giving appropriate treatments or therapies.

6
Medical Directives

Medical Records
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Most patients who have had any treatments at a hospital have a medical directive or Living Will. This document is kept on file and tells the treatment team the wishes of the patient in the event that they are unable to speak for themselves regarding their medical care.

While there are numerous other parts of medical records, these are the most common. As you can see, each is an important component of the health care puzzle. It is important that patients understand that while it is often time-consuming when to complete intake forms, they are very valuable pieces of information. Some are important for record keeping, some are important for identification, but all can be potentially lifesaving in emergency situations. With the advent of technology, medical records can be updated easily and made available nationwide further increasing their effectiveness.

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