What’s in a medical record?

The medical record contains many documents. The documents listed below are usually most helpful to patients, parents and legal guardians.

Immunizations
This report provides the information of the immunizations that the patient has had at Children’s Minnesota.

Discharge summary
This report is completed after the patient is discharged from the hospital. The report is a summary of the admission to the hospital, care provided, the diagnosis, procedures, medications, tests, immunizations, any problems and the plan for care after discharge from the hospital.

History and physical (H&P)
The history and physical report is completed for every hospital admission. It gives a detailed physical examination of the patient, the history of the present illness, the family medical history, the social history and a summary of the suspected causes of the patient’s illness.

Operative report (OP report)
This report is created for every major surgical procedure for a patient. It includes the diagnosis before and after surgery as well as a detailed summary of the actual procedure.

Lab results
These are reports that contain the results of lab tests the patient has had.   These results can take a while to appear in the medical record based on how long it takes to process the lab specimen.

Pathology report
If the patient had something removed during an operation, the laboratory produces an evaluation of the tissue. This report can take a while to appear in the medical record because the evaluation can take several days.

Medication reconciliation
This form is required both at admission to the hospital and discharge from the hospital. It lists all the medications the patient takes or needs to take at home.

Consultations
Often, a patient will require the advice of an expert physician, called a consultant. The consultant must complete a report of the visit and examination. This report is a specialized history and physical examination that focuses on a particular problem or diagnosis.

Discharge instructions
This form is completed for every patient who has stayed in the hospital. It lists diagnosis, diet limitations, activity limitations and follow-up visit instructions.

Outpatient visit documentation
This report is completed for patients seen in our clinic or outpatient settings.   The report may contain a summary of the reason for the visit, problems, physical examination, immunizations, tests ordered, care provided, medications, treatment plan and follow-up care.