- A Legal Record of your Hospital Visits
- Includes Reports of, For Example, All your Blood Tests, Surgeries, Examinations and X-rays
- Also Includes Notes by All Physicians, Nurses and Many of the Other Professional Staff (i.e. Dietitians)
- Although Charts were in Paper Format in The Past, Most Hospitals have Converted to EMRs (Electronic Medical Records)
- EMRs Have Increased Access to Date Within and Out of the Hospital and Made Storage of Medical Records Much Easier but Privacy Concerns Exist
- You are Entitled to a Copy of Your Hospital Charts
WHAT IS A HOSPITAL CHART?
The hospital chart is a confidential record of your hospital stay and vital statistics. It includes notes from doctors and nurses on everything from the state of your mind to the state of your bowels. The initial portion of the chart contains the information you gave to hospital personnel when interviewed and examined upon arriving to the ER and/or your hospital room. The rest of the chart includes lab results, medical notes, and previous hospital records.
WHAT IS A MEDICAL HISTORY?
|The Chief Complaint||
A one- or two-line statement, usually in the patient’s own words, regarding why he or she has come to the hospital
|History of Present Illness (HPI)||
A narrative description of the patient’s present problem. E.g., the HPI for a patient admitted for angina (heart pain) will describe smoking habits, but not a previous skin cancer
|Past Medical History (PMHx)||
Includes reports on previous surgeries and hospitalizations, other serious illnesses, medications, allergies and habits (smoking, alcohol consumption, etc.)
Recounts your marital status, occupation, and living situation (home, skilled nursing facility, etc.)
Contains ages and a history of health problems of parents, siblings, children and other close relatives
|Review of Systems||
A sometimes-lengthy survey of the functioning of every organ system in your body.
Your history is taken and a physical exam is done when you arrive in your hospital room. You may be interviewed more than once, and asked questions you have already answered. Do not get frustrated!
The more is known about you the better your care will be, and redundant interviews are a way to ensure all relevant information is accurately recorded. Some questions can seem intrusive or embarrassing, but you should answer everything honestly. It’s important to remember that all information is kept strictly confidential and will not be disclosed to anyone without your permission.
BASIC COMPONENTS OF MEDICAL HISTORY
WHAT DOES A BASIC PHYSICAL EXAMINATION INCLUDE?
The physical examination might be performed by anyone from a nurse or medical student to the attending physician. It starts with basic description (general appearance, age, gender, etc.) and vital signs (temperature, pulse, blood pressure, respiratory rate, etc.). Next is an examination of the patient’s organ systems.
There are four components to any description of an organ system:
A methodical, visual inspection noting everything from skin tone to cleanliness. Medical professionals are trained to identify and contextualize relevant visual cues
A physical inspection with the hands. A good physical examination includes palpation of every area and organ—skin, hair, glands, breast, heart, liver, spleen, abdomen, etc.
This is what physicians are doing when they tap their fingers on you. The various parts of the body make different sounds when percussed, and can offer clues to your state of health
Listening, generally with a stethoscope, to various organs
WHAT DO YOU DO WITH A HISTORY AND PHYSICAL EXAMINATION?
After the fact-finding and information gathering, the physician gives his or her analysis of the exact nature of your problem, this is known as the “Clinical Impression.” Based upon the Clinical Impression, a “Plan” is formulated that comprises all of the specific examinations required to verify diagnosis, or a discussion of proposed treatments.
HOW ARE CHARTS MAINTAINED AND STORED?
Notes on the patient’s condition, progress and other tests are entered at least once a day by nurses, attending physicians, consultants, physical therapists and others. A hospital chart is a legal document, so there are reams of rules regarding what to include, how to sign progress notes, and even what color ink to use. After a you are discharged, a chart is put into storage. Hospital charts are never discarded, although they may be sent off-site or converted to microfilm after a number of years. In contrast, physicians in private practice need only keep records for six and a half years, or until the patient is 21 years old, whichever comes later.
COMMON CHART ABBREVIATIONS
|“W” white||“ABG” arterial blood gases||“PID” pelvic inflammatory disease|
|“B” black||“AML” acute myelogenous leukemia||“PPD” or “PACK/DAY” refers to cigarettes|
|“H” Hispanic||“ASHD” arteriosclerotic heart disease||“PMHx” past medical history|
|“6” man||“CAD” coronary artery disease||“PVD” peripheral vascular disease|
|“9” woman||“CML” chronic myelogenous leukemia||“SIEP” serum immunoelectrophoresis|
|“C” with||“EKG” electrocardiogram||“TAH” total abdominal hysterectomy|
|“S” without||“HCT” hematocrit||“TB” tuberculosis|
|“HX” history||“HG” hemoglobin||“TFT” thyroid function tests|
|“CP” chest pain||“IEP” immunoelectrophoresis||“TURP” transurethral prostatectomy|
|“CXR” chest X ray||“LMD” local medical doctor||“UGI” upper gastrointestinal|
|“RX” treatment||“MI” myocardial infarction (heart attack)||“URI” upper respiratory illness|
|“SX” symptoms||“PFT” pulmonary function test||“UTI” urinary tract infection|
|“TX” transfusion||“PPD” purified protein derivative||“WBC” white blood cells|
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