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Medical records

Home Patients & visitors Medical records

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. 

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.