The U.S. Department of Health & Human Services provides sample medical records, reports the official website. Medical records feature important patient information. This includes personal identification information, personal and family medical history, medication history, treatment history, and medical directives, says About.com. Medical records are free of assumption, personal comments about the patient and subjective opinions, states Texas Medical Association. Including personal feelings and thoughts may work against health care professionals when facing malpractice allegations.Continue Reading
Medical records contain identifying information, such as name, date of birth, address and phone number. Medical records may also contain a Social Security number or driver’s license number. Facilities typically give each patient a special ID number. Medical history includes all diagnoses, treatments and allergies a patient currently has or had in the past. The family medical history section help doctors to diagnose hereditary conditions, notes About.com.
Medications are documented to keep track of what a patient is ingesting. All medications have an effect on the body in some way. A patient’s treatment history saves time via bypassing the same tests and remedies. This also saves patients money and unnecessary treatments. Medical directives are common for patients who have been treated at a hospital. It notes the requests of patients if they are unable to speak for themselves, states About.com.Learn more about Conditions & Diseases