3 Important Components of Every Patient’s Medical Record

If you were born in a hospital, you have a medical record. If you ever went to public school, you have a medical record. Almost every human on the planet has some sort of medical record on file with one or more medical providers.

However, do you know what’s in that file? Did you know what’s in that file (or not in it) could cause major errors? Some that can make you sick?

Here we go over the most important components of every medical record so you can make sure your doctor knows all they need to know.

1. Complete Personal Information and Updated Emergency Contacts

When you go into the medical system, due to HIPAA regulations, the staff will verify your identity with your personal information. This might be your birth date or other info.

But, if this information is incorrect you’ll have to jump through hoops to prove that you have the correct information and there is a typo in your records.

Also, having the correct emergency contact on file with your primary care physician is imperative. Say you faint in the waiting room and can’t drive yourself home? They won’t know who to contact to come to pick you up.

Having outdated information causes major confusion so make sure to doublecheck whenever you go into the office.

2. Complete and Up-To-Date Current Medications List

Most people are on multiple prescription medications. Anyone on your healthcare team needs to know exactly what medications you’re taking at all times.

It’s a good idea to keep a list on hand, or even make a graph, outlining all the medications and their dosages. Bring the list with you to all your appointments so you can doublecheck against what they have on file.

Remember to include all over-the-counter medications you take regularly as well. Drug interactions are serious and cause significant complications.

3. Your Complete Medical History

In the same way that current treatments can interact with medications you’ve been taking for years, incomplete medical histories waste time and can lead to bad combinations.

For instance, if you come in with abdominal pain and the doctor has no clue you’ve already had your gallbladder and appendix removed, they’re going to run unnecessary tests and delay the treatment for the actual problem. They’ll go to these afflictions first because they are a couple of the most common.

Making sure all surgeries, hospital stays, and ongoing illnesses are listed in your chart is imperative to give you the best care possible. Don’t forget to include dental surgeries and a current list of all vaccinations.

Making Sure Your Medical Record Is Complete Is up to You

At the end of the day, you are your best healthcare advocate. Make it a point to check your medical record and the information in it regularly. Contact your primary healthcare team whenever there is a change and update the record.

This diligence could be the difference between life and death someday.

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