Medical Record Request

The following provides a brief summary of the various parts of a medical record, which may help to identify the information you wish to request.

To request medical records call 937.547.5732. Department hours are Monday - Friday, 8:00 am to 4:30 pm. A medical release form must be signed by the patient or legal guardian to receive records. The release form is available in the Health Information Management Department. Proper identification will be required to obtain the records.

Release of Information

An agreement or acknowledgment, generally written, from a patient or caregiver that records and documents may be shared among other health care providers.

 

Discharge Summary

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 includes the present chief complaint, history of the present illness, past medical history, personal history, family history, and a review of systems.

 

Consultation Report

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.

 

Nursing Notes

This is a 24-hour account of a patient's wellbeing as checked by the patient's nurse.

 

Radiology Report

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 the Radiology department the telephone number is 937.547.5715.

 

Laboratory Results

An analysis of blood or urine and surgical pathology reports or biopsies that document tissue examinations, among others.

 

Medication List

This is a daily account of all medications and dosages administered to a patient during their stay.