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A medical chart serves as a record of pertinent facts related to a patient’s medical care. Charts are intended to be comprehensive, encompassing the entirety of information available in the patient’s complete health record. A digital version of the chart often exists as an electronic health record (EHR).
Information documented in a chart often includes but is not limited to the following:
- An initial/chief complaint and present symptoms
- A review of systems, or associated questions pertinent to the chief complaint
- A physical exam
- Relevant medical history, including any prior diagnoses, ED visits, hospitalizations, surgeries or known medical conditions
- Current medication lists and any relevant medications prescribed in the past, and any drug or other allergies
- A narrative of past interactions with physicians and other healthcare providers, including the results of each visit or hospitalization
- Results of diagnostic tests and imaging
- Medical procedures, past and pending
- Any diagnosis, differential diagnosis considerations, or other conclusions drawn by clinicians
- A summary of the above thoughts and a plan of care, including any new or change in medications, follow up testing and appointments
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