A medical records chart is a collection of detailed information about a patient’s care from the time he enters a medical facility until his discharge. It can serve as both a medical and legal record. A medical records chart is divided into sections. The section names and the information included in each section vary from one facility to another. However, some sections are likely to be included in all medical records charts.
The administrative data section contains basic information obtained at the time of admission, such as patient contact and demographic information, insurance contact information and a review of the patient’s physical examination and medical history. Legal information, such as a living will, signed consent forms granting permission for tests and procedures and signed release forms granting permission to release information to another medical facility, may also be included in the administrative data section.
Consultations, Medication and Treatment
The consultations section contains summaries of diagnostic procedures and results of diagnostic evaluations, such as laboratory tests or radiographic images. Notes from specialized diagnosticians, psychiatric, dental and podiatric reports and a consulting pharmacist’s flow sheet may be included. The medication section lists all medication given to the patient. Insulin control sheets are included for a diabetic patient. The treatment section lists everything done to treat the patient. Flow sheets list in a table format specific aspects of routine patient care, such as the taking of vital signs.
Orders, Notes, Lab Reports and Therapy
The orders section contains orders by doctors, nurse practitioners and physician assistants. The notes section contains ongoing progress notes by all involved in the patient’s care. For example, the notes section may contain dietary progress notes from a dietitian. The lab reports section contains results of laboratory work, x-ray results, electrocardiogram reports and immunization records. The therapy section contains physical therapy reports, occupational therapy reports and speech and audiology reports.
Care Plans and Discharge
The care plans section describes the treatment planned for the patient during the time remaining in the facility and after discharge. It also identifies the goal of the treatment. Depending on the patient’s condition, there may be several care plans. For example, there may be a care plan for nursing and another care plan for physical therapy. The discharge section contains instructions for the patient to follow after being discharged from the facility and final reports from those involved in his care.