What information is contained in medical records?

In short, more information is contained in medical records than most people imagine. Here’s an overview:

 

·        General information about where you live, your place of employment, your martial status, the number and ages of your kids, your phone and cell phone numbers, your insurance information, your social security number, names and numbers of people you consider “emergency contacts” and so forth.

·        A complete Health History that is obtained as you answer a detailed questionnaire about every type of disease you may have encountered in the past, including: heart issues, lung problems, autoimmune diseases, endocrine problems, chronic pain, dermatology concerns, mental health treatments and diagnosis and so forth. Not only is your own health history documented, the health history of your parents and grand parents is recorded  (if known) because many health problems, especial heart problems and some cancers, have a genetic link. 

·        Immunization records are found in health records. Though this may seem only important for children, it is important for all ages: perhaps an adult once lived in another part of the world and received a certain type of tuberculosis vaccine that would create a false-positive for a TB skin test. Correct information in this type of scenario could save that patient a lot of needless worry and expense.

·        A record of tests and lab work includes simple things like blood work to check your cholesterol levels or more complicated tests like biopsies or diagnostic imaging tests (MRI).

·        Records of previous illnesses and treatments are included in the medical records, even if the treatment was received in another location. This would include previous hospitalizations and surgeries and so forth. This is helpful for the medical team in the advent that the same problem re-emerges and further care is needed: for example, if a certain antibiotic was given and found  to be ineffective in a previous illness, then this information would be vitally important in future treatments.

·        Drug or other allergies are usually recorded in highly visible places. Both paper and paperless charts will have red-flags or stickers to get the attention of health care providers of serious drug allergies. These allergies can include certain drugs, such as penicillin, or can include things products like latex. If the patient has serious or even mild food allergies, such as to egg products or wheat of peanuts, this type of information is also made highly visible. This is because some medicines may be formulated using the known allergens.   People with celiac disease, a kind of wheat allergy, must be particularly mindful of this fact.

·        Drug or alcohol abuse is included in one’s heath record. This is very important for the physician as he or she would seek to help a recovered or recovering abuser “stay clean” by carefully prescribing medicines such as pain pills and cough medicines. 

·        Social Historymay be another private matter that is recorded in one’s medical record. This could include the type of social interactions that patient has, his sexual preference and history, and issues like physical, emotional or sexual abuse that may have occurred.

·        Habits that are considered “unhealthy” like smoking or alcohol abuse would be recorded in one’s health history as well as “good” habits like exercise or strict adherence to a specific type of diet. 

·        For women, a complete Obstetric History is included with the number and duration of pregnancies, number of miscarriages or abortions and other issues in reproductive health, such as birth control and sexually transmitted diseases (important information detailed for both men and women). 

·        For children, a growth chart would plot height, weight and head circumference on a chart and compare them to national averages according to the child’s age. This information can help detect developmental delays during a time when help and intervention is possible.