Health Information Management

Maintainer's Website: http://www.emoryhealthcare.org/patient-guide/medical-records.html

Medical Records: Adults

This series documents the medical history of adults seeking care or service from an Emory Healthcare provider or facility. This series may include, but is not limited to: personal and family medical history; physical examination report; laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; medical and surgical treatment notes and reports; evidence of medication and dosage administered; tissue reports; physician, nurse, and therapist progress notes and reports; discharge summary; treatment plans; operative and postoperative reports and progress notes; mental status examination and assessments; physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on medical device transplant; bone marrow test reports; dialysis records; interpretations of the EEG, EKG, and fetal heart monitor tracings; nuclear medicine reports; x-ray interpretations; autopsy findings; and death certificate.

Medical Records: Index

This series documents patient identification, registration, medical, and billing information for each individual registered at the hospital. This series may include, but is not limited to: demographic data, encounter data, and admissions, discharge, transfer (ADT) data.

Medical Records: Minors

This series documents the medical history of minors seeking care or service from an Emory Healthcare provider or facility. This series may include, but is not limited to: personal and family medical history; physical examination report; laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; medical and surgical treatment notes and reports; evidence of medication and dosage administered; tissue reports; physician, nurse, and therapist progress notes and reports; discharge summary; treatment plans; operative and postoperative reports and progress notes; mental status examination and assessments; physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on medical device transplant; bone marrow test reports; dialysis records; interpretations of the EEG, EKG, and fetal heart monitor tracings; nuclear medicine reports; x-ray interpretations; autopsy findings; and birth or death certificate.

Organ Donation Logs

This series documents the evaluation and determination of potential organ donor and recipient suitability.