Each time you visit your physician or other healthcare provider, records are created and stored based on the information you share with your doctor and the results of any tests or diagnostics. But what exactly is contained within the medical records that your doctor keeps about you?

Your health history, health assessments, diagnoses, results of laboratory tests, treatments, and progress notes from your doctor are all part of your medical records. More specifically, your records may contain some or all of the following information:

Demographics: Your contact information at home and work, your emergency contacts, and your health insurance policy number may be found in your medical records, as well as any other information that you provided in writing on a form when you were registered as a new patient. This may include details on race, religion, marital status, and occupation.

Prescriptions and vaccinations: Current and previous medications prescribed to you, as well as your medical allergies and immunization record.

Test results: The results of lab reports and blood tests, imaging and X-rays (mammograms, ultrasounds, and scans), biopsies, and specialized testing are included, as well as results of your physical exam/vital signs.

Progress notes: Written comments of “medical encounters” made by your physician, nurse practitioner, or others examining you that reflect their observations of your chief complaint, related symptoms, response to treatment, their assessment of the cause of your condition, physician’s orders, and their plans for next steps. These notes may be extensive if you have been hospitalized, as daily updates are made by various members of the healthcare team and entered into the medical record. Your record may also contain an opinion about your condition made by a physician other than your primary care physician, if your doctor requested an outside consultation. 
 Medical history: This is meant to provide a perspective of your health over time by recording your major and minor illnesses and health conditions, as well as those of immediate family members as they pertain to your own genetics. History on file may include:

Social history: Your relationships and sources of community support, 
career and schooling, or any related information about your commitments and interactions that might help the doctor understand the development of certain conditions.

Family history: Health status of family members, conditions they have or had, and causes of death if applicable.

Sexual history: Details on sexual activity, birth control, pregnancy (outcomes and complications), sexually transmitted diseases, sexual orientation.

Substance abuse/mental health: Diagnosis or treatment related to drugs, alcohol, or mental illness.

Illness/disease: Any major illnesses you have had, as well as chronic conditions, HIV status.

Surgical history: Dates of operations, details of procedures, and reports/results on surgeries and pathology. A discharge summary may also be included, which lists therapies provided, response to treatment, condition at discharge, and instructions for follow-up care.

Health habits: Tobacco use, alcohol intake, exercise, diet.

There are a number of other items that may find their way into your medical record, such as copies of your consent forms for treatment and release of information, digital images, data from medical devices, chemotherapy protocols, and evaluation/progress forms from specialized services like psychotherapy, physical therapy, or intensive care, to name some of the possibilities.
 If you are in doubt about what’s in your medical records, it’s your right as a patient to request a copy of them from your doctor’s office. It’s also a good idea to keep your own personal health records, and to partner with your healthcare providers as needed to help ensure accuracy.