How Medical Records Are Structured

What It Is

A medical record is the documentation of a person's health care. It includes what was discussed, what was found, what tests were done, and what plans were made. Records help different clinicians share information and keep care consistent.

Electronic health records organize information into sections and tabs. Patient portals show parts of the record, such as visit summaries, test results, and medication lists, but may not show everything.

This guide describes common structures in general. It does not interpret any individual's record. Questions about what a specific entry means are best directed to the care team that wrote it.

Common Terminology

Electronic health record (EHR)

A digital version of a person's medical record used by health care organizations.

Patient portal

A secure website or app where people can view parts of their records and message their care team.

SOAP note

A common note format with four parts: Subjective, Objective, Assessment, and Plan.

Problem list

A list of current and past health conditions or concerns.

Discharge summary

A summary written when a person leaves the hospital, describing the stay, findings, and follow-up plans.

Differential diagnosis

A list of possible conditions a clinician is considering, not a confirmed diagnosis.

Addendum

Information added to a note after it was first completed.

Where You May See These Terms

Record structure and terms show up in:

• Patient portals and visit summaries.
• Copies of records requested from a clinic or hospital.
• Referral letters and notes shared between specialists.
• Hospital admission notes, progress notes, and discharge paperwork.
• Insurance forms and documents for school, work, or travel.

Key Concepts

Common sections of a medical record:

• Demographics: name, date of birth, contact information, and insurance details.
• Problem list, past medical history, surgical history, family history, and social history (such as smoking or alcohol use).
• Medication list and allergy list, including the type of reaction when known.
• Clinical notes from visits, phone calls, and hospital stays.
• Results: lab tests, imaging reports, pathology reports, and other studies.
• Orders, referrals, immunization records, and care plans.

Examples

General examples of how notes are organized:

• Subjective: what the person reports, such as the main concern (chief complaint) and history of the present illness.
• Objective: measurable findings, such as vital signs, exam findings, and test results.
• Assessment: the clinician's summary of what may be going on, sometimes including a list of possible diagnoses.
• Plan: next steps discussed, such as tests, referrals, treatments, and follow-up.
• A discharge summary usually lists the reason for admission, the hospital course, results, medicines at discharge, and follow-up instructions.

Tips for Reading

General tips for reading medical records:

• Check the date and author of each note to understand when and by whom it was written.
• Terms like "rule out" or "differential diagnosis" mean something is being considered, not confirmed.
• Words like "denies" (the person said they do not have a symptom) and "unremarkable" (nothing unusual found) are standard wording, not judgments.
• Look up unfamiliar abbreviations in a trusted reference, while remembering that meanings depend on context.
• Notes may be copied forward from earlier visits, so some information may be out of date.
• If something looks incorrect, people in the US generally have the right to request a correction (an amendment).

Getting Clarification

Getting help with medical records:

• The care team that wrote a note is the best source for what it means.
• Medical records or health information departments can help with copies and correction requests.
• Portal messaging is often used for non-urgent questions.
• Bringing printed notes and a list of questions to an appointment can help focus the discussion.

Questions to Ask a Healthcare Professional

General questions people often find useful to bring to an appointment:

• What does this term or abbreviation in my note mean?
• Is this condition on my problem list current or from the past?
• Is my medication and allergy list up to date?
• How can I get a full copy of my records?
• How do I request a correction if something seems wrong?
• Which parts of my record can I see in the patient portal?

Sources

This guide was written in plain language from the following authoritative references.

1. Individuals' Right under HIPAA to Access their Health Information — U.S. Department of Health and Human Services (HHS)
2. Personal Health Records — MedlinePlus (U.S. National Library of Medicine)
3. Understanding Medical Words: A Tutorial — MedlinePlus (U.S. National Library of Medicine)

Related Guides

• Medical TermsCommon Medical AbbreviationsA plain-English guide to common medical abbreviations seen in visit notes, lab reports, prescriptions, and hospital records, such as BP, CBC, and PRN.
• Medical TermsHow to Read a Lab Report (General Guide)General guide to the parts of a lab report: test names, results, units, reference ranges, and H/L flags, and why results are interpreted by a clinician.
• Medical TermsPrescription Label TermsGeneral guide to the parts of a prescription label: drug name, strength, directions, refills, warnings, and other common terms and abbreviations.
• TestsCommon Terms in MRI ReportsA general glossary of terms often seen in MRI reports, such as hyperintense, enhancement, and incidental finding. Educational only, not interpretation.