The Patient Medical Record

A patient’s medical record, also referred to as a health record or medical chart, contains the proper identification of the patient and the documentation of a patient’s medical history with a particular health care provider. Keeping current and accurate medical records written and maintained by medical professionals is a key requirement for any health care provider.

Medical records have traditionally been written on paper and maintained in file cabinets full of divided folders. A patient’s current records usually reside at the health care providers offices with old records archived in another location. Electronic medical records have been developed in recent years which has changed the format of the medical record and has vastly increased their accessibility. In Indiana, a patient may request a copy of their medical record at any time.

Patients have the right to request a change or amendment to their medical record. Any requests must state which portion of the record the patient wants amended and how they want it to be amended. The request must be in writing, signed and dated. Once a request is made, the physician or provider has the right to decide if the changes will be made. The physician or provider may agree, partially agree, or disagree with the patient’s request. Once the provider’s decision is made, both the patient’s request and the provider’s or physician’s decision will be recorded into the patient’s medical record. If a change occurs, the provider must make a reasonable effort to inform anyone else who received the original medical record that a change has occurred, especially if the changes or amendments could lead to the harm of a patient if the information is not shared.

A good example illustrating why someone may want to request a change to their medical record is if an error was made when the initial medical, family, or social history was taken. For example, a patient may inform their doctor that they drink an average of 5 alcoholic beverages a week, but the doctor may have incorrectly recorded the information as 5 alcoholic beverages a day. Obviously this is a big difference and could lead to an error in treatment, so the patient will likely want to request a change to their patient record.

The patient’s medical record may include:

  • Allergies
  • Assessments and plans
  • Blood tests
  • Cat scans
  • Chemotherapy protocols
  • Complaints and symptoms
  • Current illnesses
  • Digital images of the patient
  • Diseases
  • EKG tracings
  • Family history
  • General observations
  • Growth landmarks and development history
  • Habits
  • Hospital admission documentation
  • Informed consent forms
  • Major and minor illnesses
  • Medical encounters
  • MRI’s
  • Obstetric history
  • Orders and Prescriptions
  • Outputs from medical devices
  • Pathology results like biopsy results
  • Physical examinations
  • Pregnancies and pregnancy complications
  • Prescriptions and medications
  • Progress notes
  • Radiology examinations and x-rays
  • Shots and vaccinations
  • Social history
  • Surgical history
  • Test results
  • Test results
  • Therapies
  • Vital signs