The contents of a medical record contain details of a patient’s personal and medical information. This includes personal details such as name, date of birth, marital status, contacts and allergies. The medical details reflect a patient’s past and current medical status and treatment plans.
Specific medical details include reports of significant consultations, diagnostic tests, clinical evaluations, medications, progress reports, unresolved issues, immunizations, family history and any other relevant medical history. Social history, such as living situation and risk behaviors, are also included in medical records. The contents are arranged in chronological order, and the medical professional who makes each entry dates and signs it.