Medical records and your personal health record (PHR) are different from each other. Medical records include information about your health compiled and maintained by each of your doctors or health care providers.

A PHR is information about your health compiled and maintained by you and effectively used to improve the quality of your healthcare. Create your own PHR and get active in monitoring your health and healthcare. PHRs are an inevitable and a critical step in the evolution of health information management (HIM).

Your health record content depends on the type of healthcare you have received. Given below is a list of documents common to most health records. Reports common to most health records:

• 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.
• Check the credentials and experience of the hospital/ doctor who will be treating you, overseas.
• Medication Record � A list of medicines prescribed or given to you.
• History and Physical � 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.
• Progress Notes � Notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment, their observations and plans for continued treatment.
• Consultation � An opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician.
• Physician�s Orders � Your physician�s directions to other members of the healthcare team regarding your medications, tests, diets, and treatments.
• Imaging and X-ray Reports � Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.
• Lab Reports � Describe the 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 � A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu. Parents should maintain a copy of their children�s immunization records with other important papers.
• Consent and Authorization Forms � Copies of consents for admission, treatment, surgery, and release of information.

Additional reports common to hospital stays or surgery:

• Operative Report � A document that describes surgery performed and gives the names of surgeons and assistants.
• Pathology Report � Describes tissue removed during an operation and the diagnosis based on examination of that tissue.
• Discharge Summary � A concise 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.

Your records may contain some or all of the documents above.

Having important health information such as immunization records, lab results, etc. in electronic form makes it easy for patients to update records and share them with other people who need it, including their healthcare providers and family members.

� Emergency Care or Care while traveling: Online PHRs can give health care providers valuable information on a patient in case of an emergency or if the patient requires care while traveling.

� Chronic Disease Management: Patients who have one or more chronic conditions may use a PHR monitor and record symptoms and test results (such as blood pressure or blood sugar readings). PHRs can help them track lab results, which may motivate them to adhere to the treatment plan.

� Care Coordination: If a patient�s PHR includes information from all or many health care providers, it can help them receive better coordinated care.

� Family Health Management: People who manage health care for family members �such as young children, elderly parents and spouses�often find it difficult to keep track of doctor�s appointments and immunizations for several people. Having a system for tracking and updating that information can help the caregiver coordinate their family members� health screenings/doctor visits etc. for better outcomes.

� Secure communications: Some PHRs offer a secure way for your patients to communicate with you and their other health care providers over the Internet. This can be a fast and efficient way to exchange certain types of non-urgent information�such as routine prescription requests and updateson a chronic condition.

� Ease-of-use: PHRs are designed for use by patients to help them take care of themselves and their family members.

Your health record content depends on the type of healthcare you have received. Given below is a list of documents common to most health records.

Reports Common to Most Health Records:

• 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.
• History and Physical � 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.
• Progress Notes � Notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment, their observations and plans for continued treatment.
• Consultation � An opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician.
• Physician�s Orders � Your physician�s directions to other members of the healthcare team regarding your medications, tests, diets, and treatments.
• Imaging and X-ray Reports � Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.
• Lab Reports � Describe the 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 � A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu. Parents should maintain a copy of their children�s immunization records with other important papers.
• Consent and Authorization Forms � Copies of consents for admission, treatment, surgery, and release of information.

Additional Reports Common to Hospital Stays or Surgery:

• Operative Report � A document that describes surgery performed and gives the names of surgeons and assistants.
• Pathology Report � Describes tissue removed during an operation and the diagnosis based on examination of that tissue.
• Discharge Summary � A concise 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.

Your records may contain some or all of the documents above.