Medical Records

• Demographics
• Admission and discharge information*
• Reason for visit
• Visit diagnosis
• Final diagnosis*
• Problem list
• Allergies
• Immunizations**
• Emergency department arrival information*
• Emergency department disposition*
• Emergency department notes*
• Anesthesia encounters and notes*
• Inpatient notes*
• Care plan and care plan notes*
• Patient education
• Scanned documentation
• Discharge instructions*
• Oncology treatment plans
• Oncology cancer staging summary
• Nurses' notes
• Vitals
• History & physical notes
• Medications
• Orders and results (labs, radiology results, etc.)
• Progress notes
• History and physical notes

*Notated components are found only in the hospital record and will not be part of a clinic’s record.

*History and physicals and discharge summaries may not be available if a patient’s stay was 24 hours or less.

** Immunization records may not always be available in digital format, please contact your state immunization office for full immunization records.

In accordance with the federal court decision vacating the third-party directive with the individual right of access in Ciox Health, LLC v. Azar, et al., No. 18-cv-0040 (D.D.C. January 23, 2020), HITECH authorizations will no longer be accepted in lieu of a HIPAA compliant authorization.