Release of Information: Medical Records Request
What is included within a medical record and what should I request?
The following provides a brief summary of the various parts of a medical record which may help to identify information you wish to request:
A summary of an inpatient stay. This report identifies the reason for the admission and narrates the patient's course during the stay. Diagnoses, operations performed, medications prescribed, and condition at discharge are all items of inclusion.
History & Physical
A medical history which includes the present chief complaint, history of the present illness, past medical history, personal history, family history, and a review of systems.
A report outlining the opinion about the illness or condition from a practitioner other than the attending physician.
Physician Progress Note
A specific, daily account of the patient's illness and response to treatment as noted by the physician. Notes from dieticians, physical therapists, or pharmacists, among others can also be included, which are more specifically referred to as "interdisciplinary progress notes." Physician Orders: This reports both written and verbal orders from physicians to their nursing staff and other caregivers.
This is a 24-hour account of a patient's wellbeing as checked by the patient's nurse.
This is a dictated report summarizing the findings of images or scans as viewed by the radiologist. If you would like a copy of the film on CD Radiology department the telephone number is 937.547.5715.
Analysis of blood or urine and surgical pathology reports or biopsies which document tissue examinations, among others.
This is a daily account of all medications and dosages administered to a patient during their stay.