Medical records are a combination of both self-reported patient information and a physician’s notes on diagnoses, care, and treatments. These histories involve a variety of information about a patient’s health history and personal habits, including:
Significant illnesses and medical conditions, including documentation on lab findings, diagnoses, and treatment plans.
Biographical data including any history of alcohol use, drug abuse, and smoking, in addition to physical exams, allergies, medications, and any adverse reactions.
Preventive therapies such as immunizations and screenings.
Paperwork to document services performed by medical professionals including dates, times, attending medical personnel, admittance and discharge reports, prescriptions, and any other related medical and lab reports.