A complete medical record will have a patient information form, medical history, physical examination, consent form, nursing records, doctor’s orders and progress reports, and more.

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What are the Key Components of a Complete
Medical Record?
A complete medical record will have a patient information form, medical history,
physical examination, consent form, nursing records, doctor’s orders and progress
reports, and more.
Medical practices need to maintain complete medical records with all the information about a
patient’s health condition, medical history and other vital data. Accurate medical record data
helps providers to take right treatment decisions. Today, most practitioners rely on professional
medical transcription services to create and maintain accurate medical records.
A patient’s medical history and care are systematically documented in a medical record. The
record will also contain the patient’s health information (PHI), which includes identity data,
medical examination results, and billing data. The amount, type, and degree of information
included in medical records will vary from patient to patient. The valuable information in the

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medical record helps the physician understand the patient’s health and wellness, and provide the
right care. Depending on the case, medical records may be useful in legal proceedings as well.
Key Elements of a Medical Record
1. Patient Information Form
2. Medical History
3. Physical Examination
4. Consent Form
5. Form of Informed Consent
6. Doctor’s Orders
7. Nursing Records
8. Progress Reports from the Doctor
9. Reports on Consultations
10. Additional or other Reports
11. Diagnostic Procedures and Lab Results
12. Operative Report
13. Anesthesiology Report
14. Pathology Report
15. Discharge Summary
Consistent, complete, comprehensive, and accurate information is crucial for proper care leading
to optimal treatment outcomes. It is important for medical practices, hospitals and healthcare
units to keep their medical records accurate and up-to-date. Utilize the services of a HIPAA-
compliant medical transcription company can ensure quality medical record keeping and
safeguard the privacy and security of all individually identifiable health information.