The specific content of your health record depends on the type of
healthcare you have received. Listed below are documents common to most
health records and additional documents that accompany hospital stays
Reports Common to Most Health Records:
- Identification Sheet – A form originated at the time of
registration or admission. This form lists your name, address, telephone
number, insurance, and policy number.
- Problem List – A list of significant illnesses and operations.
- Medication Record – A list of medicines prescribed or given to you.
- History and Physical – A document that describes any major
illnesses and surgeries you have had, any significant family history of
disease, your health habits, and current medications. It also states
what the physician found when he or she examined you.
- Progress Notes – Notes made by the doctors, nurses, therapists,
and social workers caring for you that reflect your response to
treatment, their observations and plans for continued treatment.
- Consultation – An opinion about your condition made by a physician
other than your primary care physician. Sometimes a consultation is
performed because your physician would like the advice and counsel of
- Physician’s Orders – Your physician’s directions to other members
of the healthcare team regarding your medications, tests, diets, and
- Imaging and X-ray Reports – Describe the findings of x-rays,
mammograms, ultrasounds, and scans. The actual films are maintained in
the radiology or imaging departments or on a computer.
- Lab Reports – Describe the results of tests conducted on body
fluids. Common examples include a throat culture, urinalysis,
cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work.
- Immunization Record – A form documenting immunizations given for
disease such as polio, measles, mumps, rubella, and the flu. Parents
should maintain a copy of their children’s immunization records with
other important papers.
- Consent and Authorization Forms – Copies of consents for admission, treatment, surgery, and release of information.
Additional Reports Common to Hospital Stays or Surgery:
- Operative Report – A document that describes surgery performed and gives the names of surgeons and assistants.
- Pathology Report – Describes tissue removed during an operation and the diagnosis based on examination of that tissue.
- Discharge Summary – A concise summary of a hospital stay,
including the reason for admission, significant findings from tests,
procedures performed, therapies provided, response to treatment,
condition at discharge, and instructions for medications, activity,
diet, and follow-up care.
Your records may contain some or all of the documents above. Depending
upon your illness or injury, you may use the services of the emergency
room, intensive care unit, a physical therapist, or home health nurse.
Often these specialized services have unique evaluation, measurement,
and progress reports wich you may also find in your health record.