01 Preparing for Care • 3 Min Read
Your medical record is a collection of information about your health and the care you receive.
It may include your health history, medications, allergies, diagnoses, test results, provider notes, care plans, and follow-up instructions. The information you see may depend on your healthcare provider and the care you have received.
You do not need to understand every medical word or review everything at once. Start with the information that matters to you right now, such as a recent test result, your medication list, or what to do next.
Your medical record has several parts. Each one tells you something about your healthcare. The sections and names may vary between healthcare organizations, but these are common examples.
This section may include past illnesses, surgeries, and ongoing health conditions.
If you notice information that seems incorrect or incomplete, you can ask your healthcare organization how to request a correction. Your request will be reviewed, but a change is not automatically guaranteed.
Your record may list medications you take, medications that were started or stopped, and known allergies. The list may not include everything you take, such as medicines or supplements from another source.
This section may include health conditions your care team is evaluating or treating, along with results from blood tests, X-rays, scans, and other tests.
Some diagnoses may be listed while your healthcare team is still evaluating a concern. Ask your provider whether a diagnosis is confirmed or still being investigated.
Primary and secondary diagnoses: A primary diagnosis is the main reason you were seen or treated — for example, pneumonia. A secondary diagnosis is another condition that also affects your care — for example, diabetes or high blood pressure.
Depending on the context, a diagnosis in your record may be confirmed, suspected, historical (from the past), or listed for billing purposes. Records also use medical terms that may be unfamiliar. Ask your care team to explain anything you don't recognize.
Some test results appear in your patient portal before your healthcare professional has reviewed them with you. A result marked high or low does not automatically mean something serious is wrong. A result within the normal range does not always answer every health question.
Do not change prescribed medications or treatment based only on a portal result.
Doctors, nurses, therapists, and specialists may write notes about your condition, treatment, and progress. Notes may include abbreviations or unfamiliar words.
This section may explain what to do after your visit. Look for:
A patient portal may show parts of your medical record online. The design and sections vary by healthcare organization.
Explore the sample sections below to see a fictional record entry and a plain-language explanation.
CarePath Patient Portal
Educational demonstration
Sample Patient Portal — Fictional Example
No real patient information
Health Record
Maria Example — Sample visit
These are examples of common medical-record sections. Select a section to see a fictional entry and what it means.
Reason for Visit — Sample entry
Cough and fever for 3 days
What This Means: This explains why Maria came for medical care. It helps the healthcare team understand her main concern.
Ask: “Does this correctly describe why I was seen?”
These sample entries are for learning only. They do not predict what your own record or results will mean. Ask your healthcare professional to explain your health information.
Your patient portal may show only part of your complete medical record. If you cannot find information you need, contact your healthcare organization and ask how to access it.
Protecting your privacy: Keep your portal username and password private, and sign out when using a shared device. Use the portal's secure messaging to communicate with your healthcare team rather than regular email or social media.
When you open your medical record, start with these questions:
Tap each stage to see what happens.
Step 1
David signs into his patient portal the day after a healthcare visit.
He reviews the visit summary and checks his medication list for accuracy.
Urgent medical concerns need prompt assistance. Do not wait for a routine portal reply. For a medical emergency, call 911 in the United States.
While reviewing her patient portal before an appointment, Elena notices a blood pressure medicine she stopped last year is still listed as active, and her penicillin allergy isn't shown. She calls the clinic, and at her visit the nurse reviews her medication and allergy lists with her and updates the record. Elena checks the portal afterward to make sure the changes appear.
Let's see what you've learned!
Great job! Understanding your medical record can help you stay informed and take part in conversations about your care.
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