Characteristics of the Health Record

Your health record, or medical chart, contains all the information necessary for your doctor to treat you. You can also keep your own medical chart, known as a personal health record. Knowing pertinent information about your health will allow you to partner with your doctor for the best health care possible.

Demographic Information and Medical History

• Health records should contain your basic information. This includes full name, address, birth date, insurance information, blood type and emergency contact. There should also be documentation of your medical history, like medical conditions, major illnesses, allergies, surgeries and medications. Carry a copy showing your medications and allergies in your wallet or purse, in case of emergencies.

Lab and Test Results

• Lab results are a major portion of the health record. Results can include blood work, mammograms, pap smears, colonoscopies, stress tests and sleep studies. Keeping records of your lab and test results will help you identify trends in your health over time, comparing lab or test results. It is especially important if you see several doctors, as one doctor may not know what tests another doctor is ordering.

Progress Notes

• Each time you see the doctor, a progress note is written and documented in the medical chart. Notes are written in the S.O.A.P format: Subjective, Objective, Assessment and Plan. Subjective information includes any complaints or changes you report. Objective information includes vital signs, like height and weight, and any test findings. Assessments include the doctor's interpretation of the subjective and objective information. The plan includes treatment options, new medications and follow-up information.

Referrals And Specialists

• If your doctor refers you to a specialist, progress notes from these specialists should be included in your medical chart. Each facility will create a new medical chart for you; for example, if you start physical therapy, the physical therapist will keep her own medical chart for you. It is always a good idea, however, to ask specialist to send progress notes to your primary care physician. This will help your doctor coordinate your health care.