Parts of Patient Medical Records

Parts of Patient Medical Records

Registration

Click each tab to learn more about the parts of a patient's medical record.

Medical History

Physical exam

Labs & Tests

Outside Docs

Consent Forms

Treatment Plan

Communication

Discharge Info

Discharge Info

This section contains information regarding the patient's discharge from the hospital, including discharge summaries, follow-up care instructions, and prescribed medications. Medical assistants should confirm that discharge instructions are clear and that the patient understands their follow-up care plan.

Communication

This section includes documentation of all interactions with the patient, such as phone calls, emails, and in-person discussions, as well as communications with other healthcare providers about the patient. Medical assistants should ensure accurate and detailed notes are recorded.

Labs & Test Results

This section contains the results of laboratory tests and diagnostic imaging, such as blood work, urinalysis, X-rays, and MRIs. Medical assistants must be aware of critical values and trends that could indicate the need for urgent medical intervention.

Consent Forms

Consent forms include signed documents where the patient agrees to specific treatments, procedures, or the release of their medical information. Medical assistants must verify that all necessary consent forms are completed and signed.

Physical Exam

These forms document the findings from the patient's physical examination, including vital signs, general appearance, and the condition of major body systems. Medical assistants should note any abnormalities or changes in the patient's baseline health status.

Medical History

Records a patient's comprehensive medical background, including their social and familiy histories, medications, and past illnesses. It Also includes their chief complaint. Medical assistants must ensure the form is thorough and filled out accurately, capturing the patient's own words, and attach any relevant medical documents to ensure a complete and useful medical record.

Medical History

This section includes the patient's past and present medical conditions, surgical history, allergies, medications, and family medical history. Important details for medical assistants include chronic illnesses, previous surgeries, and any known drug allergies to avoid potential complications.

Outside Documents

Outside documents include medical records from other healthcare providers, such as specialist consultations, previous hospitalizations, and treatment plans. Medical assistants should ensure that these documents are accurately incorporated into the patient's current medical record for comprehensive care.

Registration

The patient registration section includes personal information such as the patient's full name, date of birth, contact details, insurance information, and emergency contacts. Medical assistants should ensure that all fields are accurately filled out and up-to-date to facilitate smooth communication and billing processes.