-Name

-Adress

-DOB

Gender

Allergy records

address

phone number

Nationality

• Full legal name

• Date of birth

• Gender

• Nationality/ethnicity (if required)

• Address

• Phone number

• Email (if available)

- History

-Lab results

- vital signs

-medications

- Full name

- Date of birth

- Gender

- Address & phone number

- Emergency contact

- Insurance details

- Date/time of admission or visit

- Consents (treatment, release of info)

MRN or URN

Insurance number

Tax records

1. Patient Demographics – Name, DOB, gender, address, contact, insurance.

2. Administrative/Legal – Admission/discharge dates, encounter type, consents, advance directives.

3. Medical History – Chief complaint, past history, family/social history, allergies, immunizations.

4. Clinical Documentation – Vital signs, exams, progress notes, diagnoses, treatment plan, medications, orders.

5. Diagnostics – Lab results, imaging, pathology, procedures.

6. Treatment & Care – Medication records, nursing notes, therapy, nutrition, patient education.

7. Surgical/Procedural – Pre-op assessment, operative notes, post-op care, complications.

8. Discharge & Follow-up – Discharge summary, medications, follow-up, patient instructions.

9. Financial Data – Billing, insurance claims, coding.

10. Quality & Safety – Incident reports, infection control, audit trails.

-patients medical record filed

-duplicated files thats made by nurse might have changed the information.

-quality of papers and devices

-uses devices to insert data of patient instead of paper based.

-insurance information and certificate.

-Insurance and billing details.

-Appointment and admission records.

-Staff schedules and hospital resources.

-Helps in organization, planning, and smooth running of healthcare.

-insurance number

-scheduling appointments

• Patient full name (first, middle, last)

• Date of birth / age

• Sex / gender

• Ethnicity / race / nationality

• Contact details: address, phone number(s), email

• Emergency contact / next of kin

• Unique identifier(s) (medical record number, patient ID)

• Medical history (past illnesses, surgeries, hospitalizations)

• Family medical history

• Current medications (including dosage, over‐the‐counter)

• Allergies / adverse reactions

• Immunization / vaccination records

• Vital signs (temperature, blood pressure, pulse, respiratory rate, height, weight)

• Diagnoses / problem list

• Procedures / surgeries done

• Laboratory & diagnostic results (imaging, tests)

• Progress notes / encounter notes (including symptoms, assessment, plan)

• Treatment plans & follow‐up data

• full name

• address

• gender

• phone number

  
  

• Insurance / payer information (policy number, coverage)

• Billing / charges / cost data

• Date & time of service / encounter (admission/discharge)

• Provider information (who saw the patient: doctor, nurse, etc.)

• Consent forms & legal authorizations (for treatments, procedures)

• Patient’s employment / employer information (sometimes relevant for billing or exposures)

• Educational level / social determinants (like marital status, education) when applicable

• Record of referrals, transfers between providers / facilities