5 Types of Healthcare Documents Often Used in Medical Facilities

Most people don’t realize it, but about 3% of the population has a fear of doctors in the United States.

There are many reasons to avoid going to the doctor, especially if you’re scared of a bad diagnosis.

If you want to prevent a fear of going to the doctor, you must do what you can to remain in control and get prepared.

Keep reading if you want to learn about the most common healthcare documents that you’ll encounter as a patient so you don’t get overwhelmed!

1. Patient Info Leaflet

Patient information leaflets are one of the most common healthcare documents you’ll encounter.

These leaflets are a stack of papers that have questions regarding the patient’s previous and current medical history. Aside from health questions about allergies and genetics, it will also cover insurance and healthcare laws.

Patient leaflets contain important info that the office requires for billing and documentation. Sometimes, the patient info leaflets are found in medical record binders for better organization.

2. Discharge Summaries

At the end of each appointment or hospital visit, the medical staff will provide discharge summaries.

These summaries are written by a healthcare professional and contain the details of each visit. The summary will explain the purpose of the visit, what was discussed, and information about treatment.

Sometimes, test results are included in discharge summaries. This is only common, however, in clinical settings where testing resources are on site.

3. Medical History Record

Your medical history is different from the information provided in patient information leaflets.

The medical record summarizes all of your past diagnoses, procedures, and genetic conditions. This record details the dates on which the events occurred and when you’ve gotten care.

Healthcare specialists and medical translators must update records as your medical needs evolve.

4. Mental Status Examination

If you’ve undergone a mental health exam, you will receive separate documentation from your discharge papers.

Mental status exam reports review a patient’s mental abilities and can help identify health conditions. Medical specialists review the patient and write the mental status report, they then go to a medical translator for filing.

These reports are often used by primary care physicians, therapists, and psychologists.

5. Operative Report

In and outpatient surgeries can come with a lot of details, and each bit of info is critical for success.

An operative report is often given to a patient ahead of their procedure. The report reviews what the surgery will entail, how long it’ll last, and how you can get prepared. It’s also important to keep these reports since they include details about the recovery stage.

Don’t Let These Healthcare Documents Surprise You

Learning about the different types of healthcare documents can help you prepare for each appointment.

When you know what to expect for each document, you can bring the necessary information with you. Many people get flustered when they arrive at their appointments because they get a pack of paperwork to fill out. Take your time to work through each document and always check for accuracy.

If you want to learn more about healthcare concerns and managing medical records, read our blog for the latest info!