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Medical records

Home Patients & visitors Medical records

 

What's included in my medical records?

Medical records hold important information about your health history, diagnoses, conditions and treatment plans, including medications you received while at one of our facilities. Several of our hospitals are transitioning to digital medical records, which will enable us to help provide seamless information sharing between your doctors and the hospital.. Regardless in what format your medical record is kept, you have the right to access it.

Since your medical record is the property of the hospital, all medical providers involved in your care must first document your condition, treatment and the care you received before it can be released to you. If necessary, your medical record, or portions of it, may be released to one of our board-certified doctors or medical facilities for follow-up and continued out-patient care. 

Please keep in mind that medical records are confidential and to protect your information, your written authorization is required before a copy can be released. If you're age 18 or older, you can request an authorization form from the medical records office. A fee may be required.  

To learn more about our medical record system, contact the closest the Novant Health hospital in your area.

Specific information available in medical records


Medical records may consist of the following:

  • 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.