Editing Medical record (section)

==Media applied==

Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.

The advent of [[electronic medical record]]s has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the [[Mayo Clinic]] out of a desire to simplify patient tracking and to allow for medical research.{{cn|date=November 2023}}

Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.{{cn|date=November 2023}}

===Medical history===

The [[medical history]] is a [[Longitudinal study|longitudinal]] record of what has happened to the patient since birth. It chronicles [[disease]]s, major and minor [[illness]]es, as well as [[growth landmarks]]. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease state. It includes several subsets detailed below.

;Surgical history
:The surgical history is a chronicle of [[surgery]] performed for the patient. It may have dates of operations, [[operative report]]s, and/or the detailed narrative of what the [[surgery|surgeon]] did.
;Obstetric history
:The [[obstetrics|obstetric]] history lists prior [[pregnancy|pregnancies]] and their outcomes. It also includes any complications of these pregnancies.
;Medications and medical allergies
:The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.
;Family history
:The [[family]] history lists the health status of immediate family members as well as their causes of death (if known).<ref>{{cite web |url=https://familyhistory.hhs.gov/fhh-web/home.action |title=My Family Health Portrait |publisher=Office of the Surgeon General |access-date=2012-04-14 |archive-url=https://web.archive.org/web/20141006133223/https://familyhistory.hhs.gov/fhh-web/home.action |archive-date=2014-10-06 |url-status=dead }}</ref> It may also list diseases common in the family or found only in one sex or the other. It may also include a [[pedigree chart]]. It is a valuable asset in predicting some outcomes for the patient.
;Social history
:The social history is a chronicle of human interactions. It tells of the [[Interpersonal relationship|relationship]]s of the patient, his/her careers and trainings, and religious training. It is helpful for the physician to know what sorts of [[community]] support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
;Habits
:Various habits which impact health, such as [[tobacco]] use, [[alcohol (drug)|alcohol]] intake, [[exercise]], and [[diet (nutrition)|diet]] are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and [[sexual orientation]].
;Immunization history
:The history of [[vaccination]] is included. Any blood tests proving [[immune system|immunity]] will also be included in this section.
;Growth chart and developmental history
:For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.

===Medical encounters===

Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a [[medical specialist|specialist]] often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the ''problem-oriented medical record'' (POMR), which includes a problem list of diagnoses or a "[[SOAP note|SOAP]]" method of documentation for each visit. Each encounter will generally contain the aspects below:

;[[Chief complaint]]
:This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored.
;[[History of the present illness]]
:A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
;Physical examination
:The [[physical examination]] is the recording of observations of the patient. This includes the [[Vital signs (medicine)|vital signs]], muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
;Assessment and plan
:The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).

===Orders and prescriptions===
Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.

===Progress notes===

When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a [[SOAP note]] and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, [[respiratory therapist]]s, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.

===Test results===

The results of testing, such as blood tests (e.g., [[complete blood count]]) [[radiology]] examinations (e.g., [[X-ray]]s), [[pathology]] (e.g., [[biopsy]] results), or specialized testing (e.g., [[spirometry|pulmonary function testing]]) are included. Often, as in the case of X-rays, a written report of the [[Medical findings|findings]] is included in lieu of the actual film.

===Other information===
Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/[[intensive care unit]]s, [[informed consent]] forms, [[EKG]] tracings, outputs from medical devices (such as [[artificial pacemaker|pacemakers]]), [[chemotherapy]] protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.