What makes up a medical record and why?

Medical records are a collection of information about your health and illness. These records fall into five categories:

•1.  History, a summary of symptoms and events organized by medical problem, usually obtained from the patient and family or sometimes from prior medical records. Information from patients or family is referred to as "subjective." History has several subcategories, including Chief Complaint (what is bothering you most), Present Illness (your description of current symptoms), Past Medical History (older or stable problems), Past Surgical History (and procedures), Obstetrical History, Childhood Illnesses (whether you had measles, mumps, etc), Allergies, Medications, Family History (illnesses occurring in blood relatives), Social History (summary of factors such as employment, marital status and family structure, use of recreational drugs, advanced directives, etc).

•2.  Physical Examination, a description of professional ("objective") observations (called signs), organized by body systems.

•3.  Laboratory Results, a collection of reports from blood studies, body fluid analysis, tissue analysis, radiographic and other imaging studies and so forth. These types of reports are also called "objective", and are often organized first by type of study then chronologically.

•4.  Assessments and Diagnoses, the summary opinions of the physician or other healthcare provider about what disease processes explain your history, physical examination and laboratory results. Assessments are both the formal diagnoses and the accompanying explanatory statements that amplify what the physician thinks of your medical problems.

•5.  Plan, a list of planned actions organized by medical problem.

The process of medical evaluation follows the scientific method: first, observations by you (history) and by the physician (physical examination and laboratory) form the foundation of a reasonable hypothesis (assessment or diagnosis) about what illness may explain whatever pathology has been identified. A plan is generated to test the hypothesis and to treat the illness. In the case of preventive care, the plan is based on assessing what illnesses you are prone to get, and to work to prevent or minimize the illness.