Reports Common to Most Health Records:

• Identification Sheet – A form originated at the time of registration or admission. This form lists your name, address, telephone number, insurance, and policy number.
• Problem List – A list of significant illnesses and operations.
• Medication Record – A list of medicines prescribed or given to you.
• History and Physical – A document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits, and current medications. It also states what the physician found when he or she examined you.
• Progress Notes – Notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment, their observations and plans for continued treatment.
• Consultation – An opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician.
• Physician’s Orders – Your physician’s directions to other members of the healthcare team regarding your medications, tests, diets, and treatments.
• Imaging and X-ray Reports – Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.
• Lab Reports – Describe the results of tests conducted on body fluids. Common examples include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work.
• Immunization Record – A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu. Parents should maintain a copy of their children’s immunization records with other important papers.
• Consent and Authorization Forms – Copies of consents for admission, treatment, surgery, and release of information.

Additional Reports Common to Hospital Stays or Surgery:

• Operative Report – A document that describes surgery performed and gives the names of surgeons and assistants.
• Pathology Report – Describes tissue removed during an operation and the diagnosis based on examination of that tissue.
• Discharge Summary – A concise summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care.

Your records may contain some or all of the forms above. Depending upon your illness or injury, you may use the services of the emergency room, intensive care unit, a physical therapist, or home health nurse. Often these specialized services have unique evaluation, measurement, and progress forms you may also find in your health record.

By healthcare providers:

Most healthcare organizations have quality assurance departments. People in these departments review patient information in order to monitor and improve the quality of care you receive. Your information may also be used for research and as a legal document in cases where evidence of care is needed. For the most part, anyone who wants to use it for any other purpose needs your permission first.

Hospitals can share information with family members without your authorization if you are unable to consent and a family member (such as spouse, parent, or child) is involved in providing your care. For example, your spouse or child may be involved in caring for you following a hospital stay (by helping you in and out of bed, to bathe, changing bandages, and similar activities). You can simplify things at the time you are admitted to the hospital (or nursing home) by specifying which family member you want to receive information about you.

By insurance companies:

After your health information is collected, it is used to bill for the services you received.

Your patient data for billing purposes is usually transmitted electronically to those paying your bills, such as your insurance company, although the company may request paper documents in support of the bill. Your information is often identified by your name, patient identification number, address, phone number, and social security number.

Your health insurance company receives your health information through the claims provided by the patient accounts/billing department at your healthcare facility. The coded data is then evaluated automatically to identify appropriate payment for the services you received. Your insurance company may ask your provider for more information to validate payment if the claims submitted were not complete enough to support what was being billed.

It is important to understand that PHRs – which generally are not part of a provider’s electronic health record – are not considered legal health records and therefore, are not covered by HIPAA.

Chances are, you have a lot of different medical records. You may see many different healthcare providers during your lifetime such as a family practitioner, an allergist, a specialist such as a cardiologist, and if necessary, a surgeon. Each of these providers compiles a separate file of information about you. In fact, even if your providers are all part of the same health care system, they may each keep a separate medical record for you and may not be aware of the other treatment you are receiving. This can lead to an incomplete and disconnected record of your health. This is why your PHR and how you use it is important. Our experts discuss the benefits and risks involved in selecting the appropriate PHR.