What kind of information will one find in a patient's file?

Question

For a project, I am making a mock patient file's for certain characters in a story, I was just wondering what kind of info is stored into these?

Answer 1

Demographic Data
Medical record number (MRN)
Name incl previous names/name changes
Age / Date of Birth
Gender

Address
Contact Details
Next Of Kin

Then ... the next bit tends to depends on if it's a hospital file or private doctors file and what sort of doctor they are.

Usually a 1st visit type of section with
Presenting Complaint & history of presenting complaint
Past History, Occupational History
Social History
Medications, Allergies
Examination Findings

Assessment/Impression/Diagnosis/Problem List

Plan - investigations or medications or whatever

In hospital records this tends to be repeated each time the patient comes in. Then there is a section for outpatients notes and letters, a section for results etc.

In private doctors records it tends to look like the outpatients notes after the 1st presentation thing. It's essentially a chronological account of each time the patient comes back - usually for follow up or planning of some intervention... etc.

Answer 2

Name: Last, First
Birthday: MM/DD/YYYY
height, weight
medical history: surgeries, hospitilazations, accidents, births, pregnancies.
Vital Signs: blood pressure, temperature, heart rate, respiration rate.
Reason for the doctor visit
Insurance information
I can't think of anything else off the top. But I hope that helps! -Lizz