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Medical records

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Medical records

A medical record folder being pulled from the records





Traditionally, medicals records have been written on paper and kept in folders. These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (eg those of the deceased) are often kept in separate facilities.

The advent of electronic medical records has changed not only the format of medical records, but has increased accessibility of files.


Although the specific content of the medical record may vary depending upon specialty and location, it usually contains the patient's identification information; the patient's health history (what the patient tells the health care providers about his or her past and present health status); and the patient's medical examination findings (what the health care providers observe when the patient is examined). Other information may include lab test results; medications prescribed; referrals ordered to health care providers; educational materials provided; and what plans there are for further care, including patient instruction for self-care and return visits[4]. In some places, billing information is considered to be part of the medical record [5].


Demographics include information regarding the patient which is not medical in nature. It is often information to locate the patient including identifying numbers, addresses, and contact numbers. It may contain information about race and religion as well as workplace and type of occupational information. It may also contain information regarding the patient's health insurance. It is common to also find emergency contacts located in this section of the medical chart.

Medical historyEdit

The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.

Surgical history
Obstetric history
Medications and medical allergies
Family history
Social history
Immunization history
Growth chart and developmental history
For children and teenagers, charts documenting growth as it compares to other children of the same age is included so that health care providers can follow the child's growth over time. Many diseases and social stresses can affect growth and longitudinal charting can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.

Medical encountersEdit

Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (ie when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirity of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:

Chief complaint
History of the present illness
A detailed exploration of the symptoms that the patient is experiencing which have caused the patient to seek medical attention.
Physical examination
The physical examination is the recording of observations of the patient. This includes the vital signs and examination of the different organ systems, especially ones which might directly be responsible for the symptoms that the patient is experiencing.
Assessment and plan



Progress notesEdit

When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health care team (doctors, nurses, respiratory therapists, etc). They are kept in chronological order and document the sequence of events leading to the current state of health.

Test resultsEdit

The results of testing, such as blood tests (eg complete blood count) radiology examinations (eg X-rays), pathology (eg biopsy results), or specialized testing (eg pulmonary function testing) are included. Often, as in the case of x-rays, a written report of the findings is included in lieu of the actual film.

Other informationEdit


Administrative issuesEdit



In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.



In the United Kingdom, the NHS's medical records belong to the Department of Health.


In the United States, the most basic rules governing access to a medical record dictate that only the patient and the health care providers directly involved in delivering care have the right to view the record. The patient, however, may grant consent for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.

When a patient does not have capacity (is not legally able) to make decisions regarding their own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the comatose, minors (unless emancipated) and patients with incapacitating psychiatric illness or intoxication.
Medical emergency
In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been drafted previously (such as an advance directive)
Research, auditing, and evaluation
Risk of death or harm
Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (ie, information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the United States Supreme Court case Jaffe v. Redmond[6].

In the United Kingdom, the Data Protection Acts and later the Freedom of Information Act 2000, gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g. information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's well-being (eg some psychiatric assessments). Also the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.


In general, entities in possession of medical records are required to maintain those records for a given period of time. In the United Kingdom, medical records are required for the lifetime of a patent and legally for as long as the time that complaint action can be brought. Generally in the UK any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient’s death to investigate illnesses within a community (e.g. industrial or environmental disease or even of doctors committing murders, e.g. Harold Shipman). [7]



See alsoEdit


  • Berg & Goorman (1999) "The contextual nature of medical information" Int J Med Informatics 56: 51-60
  • Kay & Purves (1996) "Medical records and other stories: a narratological framework" Meth Inform Med. 5:72-87

External linksEdit

Organizations dealing with medical recordsEdit


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