Your medical records contain a wealth of information detailing health history, medical encounters, diagnoses, medications, test results, treatment plans, and more. Understanding what comprises a standard medical record and commonly used terminology equips patients to better comprehend their own health narratives, engage with providers, and identify any inconsistencies or errors that warrant correction.
Progress Notes
Progress notes represent the bulk of most medical records, capturing subjective and objective details from patient visits and encounters. Subjective statements document symptoms described in the patient’s own words. Objective findings come from the provider’s physical examination, imaging, and lab results. Assessment and plan sections then detail diagnosed conditions and outline treatment next steps.
Initial hospital admission and discharge summaries also occupy progress notes conveying critical transition events. Clinicians rely heavily on prior progress notes to make inferences regarding disease progression and treatment efficacy over time. Gaps in sequential progress notes cause confusion and unsafe assumptions about patient status.
Components of Medical History
A dedicated medical history section compiles information on conditions, surgeries, social history details related to family, work and lifestyle alongside medications, allergies, and immunizations. Family histories highlighting inherited conditions often receive prominence to watch for associated disease manifestations. For new patients, a detailed review of systems documenting the status of all body systems commonly supplements baseline health insights.
Experienced clinicians read nuances in medical histories to identify subtle clues that may inform diagnoses. Patients must confirm history accuracy at routine physicals, notifying providers regarding any missing pieces that may skew clinical decision-making. Incorrect or absent allergy documentation poses particular risks, as do outdated surgical procedure details lost through system migrations.
Order Entry and Result Details
Any tests, procedures, specialist referrals or imaging/lab orders dictated by providers also appear with correlating reports once resulted. For example, colonoscopy procedures will detail order placement alongside resultant imaging findings when completed. Specialist referral requests and returned consultant notes also reside chronologically.
Imaging orders (x-rays, CT scans) and pathology/lab test orders (bloodwork, biopsies) follow the same pattern including the provider’s clinical rationale supporting necessity. Tracing back abnormal results to originating orders provides context around concerning findings. Audit trails tracking canceled/discontinued orders prevent obsolete findings from inadvertently influencing future care.
Billing and Coding Impacts
The people at Find-A-Code.com explain that medical coding translates diagnoses, processes, procedures, lab work and other data points into universal alphanumeric values (CPT, ICD 10 codes) used for public health reporting, research, and medical billing. Issued bills derive from translating those coded elements into dollar charges based on care setting, insurer agreements, medical resources utilized and service complexity.
Bills also incorporate pharmacy charges from administered drugs identifiable by NDC (National Drug Codes) and revenue codes aggregating room/facility fees. Savvy patients can research billing codes to understand associated costs and challenge any perceived billing errors, such as duplicative or erroneous line items.
Legal Documentation
Finally, medical records house legal forms of consent for treatment, privacy practices, release of information, mental competency, operative permissions, disclosures of associated risks, death declarations and anatomical gift intentions. Durable medical equipment necessitating insurance approvals also enters documentation history.
Savvy patients can request inclusion of sensitive documents specifying advanced directives regarding end-of-life care wishes or specific medical proxies granted decision-making capacity if patients lose ability to decide treatments themselves. Executing these legally binding directives helps to bring peace of mind.
Conclusion
Medical charts accumulate extensive paperwork and digital documentation that is tied to preserving health chronicles over many years. Recognizing everything that populates records equips patients to track their personal health journeys, clarify next steps, and ultimately engage providers with well-informed questions for improved health maintenance. Keeping records accurate and complete ensures safer care delivery.
