The Content of Medical Records

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Medical records are of vital importance. Health professionals use them to make decisions about patient care and to manage that care. Medical records are effective communications tools that help doctors keep a close watch over their patients, no matter where they are. 

An Effective Communication Tool 

A medical records is opened when a patient visits a health care institution or private clinic for the first time.   

Medical records have personal information about a patient and information about the care the patient has received up to that point. 

Personal Information 

Any information that identifies a patient is considered personal information, whether it is on paper, in a computer  or in a voice recording.   

Doctors and other health care professionals enter personal information in medical records to identify their patients. Personal information includes the following: 

  • name 
  • sex 
  • date of birth 
  • address 
  • health-insurance card number (medicare card number) 

Medical Information 

Doctors and other healthcare professionals also enter medical information in their patients’ records:  

  • date of each visit 
  • allergies 
  • observations 
  • diagnoses 
  • other information that could complicate or affect the care they give