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