Medical records may consist of the following:
- Admission and discharge information*
- Reason for visit
- Visit diagnosis
- Final diagnosis*
- Problem list
- 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
- History & physical notes
- 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.