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