That depends, each office is different...
History and Physicals
Progress Notes
Test Results
Medications
Previous Physician Notes
Operation Notes
Copy of Insurance Card
Copy of Identification (sometimes)
Basically, anything that pertains to your medical history.
For a patient information
Two types of patient records are electronic health records (EHRs), which are digital versions of patient charts, and paper-based medical records, which are physical documents containing patient information and medical history.
Yes, billing information is protected health information covered under HIPAA regulations.
Medical records can't be released to anyone without signed consent from the patient. There are laws that protect the privacy of patients and their medical information called HIPPA.
A spouse can look at the patient's medical records only with the express consent of the patient.
Employers and government agencies are often a glimpse of your medical records. These information can obtained your medical records, like treatments that you have done in the past.
The Medical Records Department prepares and maintains patient records.
The patient owns the information; the doctor owns the media or paper.
Electronic health records (EHRs) offer key features such as easy access to patient information, improved coordination of care among healthcare providers, and increased accuracy of medical records. The benefits include better patient outcomes, reduced medical errors, and enhanced efficiency in healthcare delivery.
In a medical office, the two major types of patient records are clinical records and administrative records. Clinical records contain detailed information about a patient's medical history, diagnoses, treatment plans, and progress notes, while administrative records focus on billing, insurance information, and appointment scheduling. Both types are essential for providing comprehensive patient care and ensuring efficient office operations.
The person who creates the data in the record
The person who creates the data in the record