By: Plume Community Member
A medical chart or medical record is a comprehensive collection of documents that is kept by a clinic, hospital, or other healthcare organization to detail an individual’s medical history and current care. The medical chart or record typically includes data such as patient contact information, demographic information such as their gender marker, insurance information, medical history including allergies and past visits, current medications, lab results, and more. In the United States, the Health Insurance Portability and Accountability Act (HIPAA) governs the privacy and security of a patient’s medical chart or records.
The specifics of what is included in a medical chart or record will vary from clinic to clinic and from patient to patient. Generally, a medical chart or record will include a patient’s contact information, demographic information such as their gender marker, insurance information, and medical history. It may also include information such as the patient’s family medical history, current health concerns, symptoms, notes from physical exams, lab results, medication, and an overall synopsis of the patient’s health.
In addition to all of the information that is included in a medical chart or record, HIPAA also requires that a medical chart or record contain a record of when the information was updated or changed. This is important for medical providers to ensure that a patient’s medical chart is up to date and that any information that has been added or changed is accurate. Furthermore, HIPAA also requires that the patient’s medical chart or record be kept secure, meaning that only authorized personnel have access to it and that it is protected from unauthorized access or use.
In summary, a medical chart or record is a comprehensive collection of documents that is kept by a clinic, hospital, or other healthcare organization to detail an individual’s medical history and current care. It typically includes a patient’s contact information, demographic information such as their gender marker, insurance information, medical history, current health concerns, lab results, and medication. HIPAA also requires that a medical chart or record contain a record of when the information was updated or changed and that the patient’s medical chart or record be kept secure.
Co-founded by one of the leading voices in transgender healthcare, Dr. Jerrica Kirkley (she/her), Plume is the largest gender-affirming healthcare provider in the world. Plume provides care and support for gender transition. Our services include gender-affirming hormone therapy (GAHT, sometimes called HRT or hormone replacement therapy) such as estrogen and testosterone prescriptions for transgender, nonbinary, and gender non-conforming individuals. Plume also provides specialized health care for the trans community that includes peer support and medications for treating anxiety and depression. To become a Plume Member, click here.
