The specific content of a medical record depends on the type of healthcare you've received. A medical record can differ depending on whether you visited a physician's office, stayed in a hospital, used an outpatient facility, or visited your dentist.

Below are listed documents common to most physician medical records.

Documents Common to Most Medical Records

  Lab Results
  Patient physical and history
  Discharge summary
  Operative reports
  Pathology reports
  Special procedures and test reports
  Radiology (x-ray) reports

Clinical Abstract

A clinical abstract is a summary of your entire medical record. It contains the most important medical information needed for your treatment as well as general knowledge of your overall health status. Typically, most hospitals and physicians utilize a clinical abstract.


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