Required Components of Medical Records

Electronic or paper record, there are specific sections and components that are required on all patient's medical records

Administrative Sections : Demographic data

name, address, birth date, sex, gender, social security number, phone number, employment information

Administrative Sections : Administrative Data

notice of privacy practices form, Advance directives, consent forms, medical records release form

Administrative Sections : Schedule, Financial, and Billing Information

Information reguarding any appointments, insurance information, balances

Clinical Section : Health History

chief complaints, present illness, past medical history, family history, social history, review of systems

Clinical Section : Physical Examinations

Assessment of each body part

Clinical Section : Allergies

All known patient allergies

Clinical Section : Medication Record

Detailed information related to patient’s medication

Clinical Section : Problem List

problems identifies, updated each visit

Clinical Section : Progress Notes

New information each time the patient visits or telephones the office

Clinical Section : Laboratory Data

Any laboratory data

Clinical Section : Diagnostic Procedures

Electrocardiogram report, Holter monitor report, Spirometry report, Radiology report, Diagnostic imaging report

Clinical Section : Continuity of Care

Consultation report, Home health care report, Therapeutic service documents, Hospital documents