All the information about your hospital stay in one place.
A medical chart documents information about your time in a hospital or your visit to your primary care doctor. In a hospital, it’s a medical and legal record of your health problem, your care in the hospital, your medical history, and your involvement with your healthcare team.
Your healthcare team will write down information about your entire stay in the hospital. Your basic personal information will be included, such as your name, date of birth, marital status, and health insurance information.
Information on your medical chart will include:
- Your diagnosis
- Any orders for medication and treatment by your doctor, nurse practitioner, or physician assistant
- A record of medications you are taking, and any allergies you may have to medication or anything else
- All treatment you received during your stay
- How you responded to treatment
- All procedures you may have received, including diagnostic or therapeutic surgeries (such as a colonoscopy or heart surgery)
- Any tests you needed, including laboratory tests, x-rays, tests to see if there’s a problem with your heart, and summaries of the test results
- Your vital signs: heartbeat, breathing rate, body temperature, and blood pressure
- Consultations, or notes, from any specialists involved in your care
- Consents: your permission for your healthcare team to go ahead with procedures or tests, or have access to your chart
- Flowcharts that track your care
- Care plans: treatment goals and plans for future care in the hospital or after you leave the hospital
- Discharge instructions and reports by your care team before your chart is closed
If you have a do-not-resuscitate order, it will be part of your chart.
Your chart may also have special sections, depending on the hospital you are in and your care or situation. Your chart may also be called a medical record. These days you may have an electronic health record, the goal of which is to include all of your health information and history in one place.
March 03, 2015
Christopher Nystuen, MD, MBA