What is a Medical Chart?

Whenever you go the doctor or hospital, you’re sure to notice that every element of your stay is documented or written down. While this constant writing can become a little bewildering, it’s for a good cause, your complete medical records. Your doctor uses your medical records to make informed decisions about the best care for you, both in the long and the short term. In this article, we’ll discuss the ins and outs of your medical chart, what it includes and how it can be read, as well as how doctors and other medical health professionals use that information to improve your quality of care.

What Does My Medical Chart Do?
Your medical chart is like a medical snapshot of you, with all of the data and information that your doctor needs to diagnose you. It will include your physical measurements and records, along with important medical results, like blood pressure, heart rate. We’ll go through three of the most relevant sections, medical history, visit records, and surgical records, and we’ll also discuss who can access your chart.

What’s Your Medical History Doing In Your Chart?

Many people don’t understand why they need to supply so much information about their history and things they’ve experienced in the past. While it can seem like some of these questions can be intrusive, these things are important parts of your doctor knowing what’s going on with your body, and improving your quality of care. Some of the things that your doctor will want in your medical history are your family’s history of illness, like heart disease or diabetes. This is also why your doctor will ask for your demographics like race or ethnicity as well, as some conditions are more prevelent in different groups of people. Your doctor will also be interested in your childhood medical history. He or she will want to know how your childhood development went, if you had any issues with puberty, or if you might have developed a little more slowly than your age range indicates you should’ve. Your doctor will also want your immunization records, to make sure that all of your childhood vaccinations were given, and to make sure that you’re current on vaccines you might need now, like tetanus shots.
Of course, the most important part of your medical history is you! Your doctor will need to know about any conditions you might have now, like allergies or asthma, and if you’re on any medications to help them. Your doctor will be interested in many of your everyday activities that can affect your health. Expect questions like, Do you drink? and How often?. Your doctor will probably ask similar questions about smoking, recreational drugs, exercising, and other habits. Your doctor isn’t asking these questions to embarrass you or make you feel uncomfortable. These habits have a big effect on your physical health, both now and in the future.The more information your doctor has, the better he or she will be able to diagnose current issues and make sure your health is better protected in the future. Your doctor will also want to know if you’ve been on certain types of medication before and if you have any sensitivities or allergies to certain medications. Your doctor will want to know about all of your visits to their office, or to the emergency room as well. This brings us to the next part of your chart, the visit records.

What Goes In A Visit Record?

Your medical chart is a history of every interaction you’ve had with the healthcare sector over your lifetime. These histories come in the form of visit records, that keep track of what happened any time you’ve gone to see a medical professional. Anytime you go into a hospital or schedule a doctor’s appointment, that generates an entry into your chart. These entries will include information about the reason you went to the doctor’s that day, or the emergency if you ended up in an ER department. The doctors will probably ask you if you’ve had the same complaint or symptoms before since that’s an important part of finding a cause. Any notes from the exam will end up in your chart as well, along with any test results, images that are taken like x-rays or MRIs, and your doctor’s overall assessment. The chart will also include any of your doctor’s instructions for future care, as well as any prescriptions your doctor might write for you at that time. These visit records are an important part of your medical history since they allow your doctor to better see what’s been going on in your life, and your health over the last five to ten year period, and look for trends that might give them more information about what’s going on.

What About If I Have Surgery?

Surgical records will also be in your chart, though they might be a little more in-depth than a visit record. Surgical records usually go through the entire procedure and might have pictures or narration to effectively communicate exactly what happened during the surgery.

Who Can Access My Medical Chart?

Only you and doctors you are currently receiving care from can access your medical chart. It’s important to remember that your medical chart is your property, and it’s also your responsibility to make sure that the information in the chart is correct. You can get your chart amended if you find something in it that’s incorrect, and you can also discuss the information in your chart with your doctor at any time. You shouldn’t be afraid to bring up information in your chart that may by incorrect or no longer relevant. This chart is yours, and the more accurate and correct information your doctor has, the better able they will be to ensure that you have the best possible care.

In conclusion, we hope this article has helped you understand some of the main features in your chart, as well as addressing some of the common concerns that many people have about their medical charts. It’s important to remember that your chart is yours and that you can change or amend it at any time. Your doctor uses your chart to get a full and complete understanding of your medical records and history, and the more information he has, the better. Having full and complete information is what enables your doctor to give your the best care possible.