What Types of Medical Forms Do Doctors Keep in Patient Records?


Quick Answer

Some forms in a patient's medical record include immunization and health history forms, notes the University of Wisconsin-Madison. A typical medical record also contains lab test results; doctor's reports from examinations, treatments and surgeries; medication lists; and notes from other health care providers, states the University of Michigan Health System.

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Full Answer

Although clinics and hospitals usually maintain medical records, keeping a personal health record at home is also important, notes the University of Michigan Health System. The personal health record may include information about the individual and any person the individual cares for, such as a child or aging parent. A personal health record can be simple or detailed, and it typically includes a current medication list, immunization record, emergency contact, allergy list and important test results. Personal health records can also contain dental information, health insurance information and organ donor authorization, according to the University of Wisconsin-Madison.

In most cases, patients must complete an authorization form before a hospital or clinic can release copies of their medical records, explains Aurora Health Care. These forms allow patients to specify the exact information they want to receive and who is authorized to receive it. Hospitals and clinics sometimes charge fees for copies of medical records, depending on the situation.

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