Unlike hospitals, a doctor's office keeps records that are not -- yet
-- heavily regulated by the federal government. Incredibly, things usually
turn out OK even so.
If office chart organization varies quite a bit, it's also pretty simple.
Clinic
Visit
Notes |
1 |
The doctor's typed or scribbled record of each office visit. Chronological. |
Test
Results |
2 |
Lab, pathology, X-ray, EKG. Sometimes separated and sub-tabbed, sometimes
jumbled with the clinic notes. |
Outside
Records |
3 |
Letters from other doctors. Copies of hospital consults, discharge summaries,
x-rays, labs. An important section that may include records you're having
trouble getting from a stonewalling doctor or hospital. |
|
Other |
|
Occasionally office charts have separate sections for phone calls,
prescriptions, and tracking the progress of chronic diseases like diabetes. |
|
Miscellaneous |
4 |
Count on finding a few unclassifiable pages. |