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What Does PHR contain?
The specific content of your health record depends on the type of healthcare you have received. Your health record would contain:
- Identification Sheet : A form originated at the time of registration or admission. This form lists your name, address, telephone number, insurance, and policy number.
- Problem List : A list of significant illnesses and operations.
- Medication Record : A list of medicines prescribed or given to you.
- Medical History : A document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits, and current medications. It also states what the physician found when he or she examined you.
- Consultation : An opinion about your condition made by a physician other than your primary care physician.
- Physician's Prescription : Your physician's directions regarding your medications, tests, diets, and treatments.
- Imaging and X-ray Reports : Findings of x-rays, mammograms, ultrasounds, and scans
- Lab Reports : Results of tests conducted on body fluids. Common examples include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work.
- Immunization Record : Documentation of immunizations given for disease such as polio, measles, mumps, rubella, and the flu.
- Consent and Authorization Forms : Copy of consent for admission, treatment, surgery, and release of information.
- Operative History : Describes surgery performed, hospital and treating doctors
- Discharge Summary : Summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care.