Your medical records contain a surprisingly detailed portrait of your health, from basic information like your name and birth date to the specific words your doctor typed after every visit. Most records today are stored electronically, and since April 2021, federal law requires that clinical notes entered into an electronic health record be made available to you through a patient portal without delay. Understanding what’s actually in those records helps you spot errors, prepare for new providers, and make sense of the documents when you request them.
Demographics and Insurance Information
The front layer of your medical record is administrative. It includes your full legal name, date of birth, sex, address, phone number, emergency contacts, and the expected source of payment for your care. Your insurance plan details, policy number, and group number live here too. If you’ve ever filled out a clipboard of forms in a waiting room, that paperwork feeds directly into this section. It also typically includes your race, ethnicity, and preferred language, which providers collect both for communication purposes and to meet federal reporting requirements.
Visit Notes and Clinical Documentation
Every time you see a provider, that encounter generates a note. Most follow a structure called the SOAP format, which has four parts: Subjective, Objective, Assessment, and Plan.
The Subjective section captures what you told your provider. It starts with your reason for the visit (the “chief complaint”), then records details like where a symptom is located, how long it’s been happening, what makes it better or worse, and whether it comes and goes. If you mentioned that your knee pain gets worse when climbing stairs, that detail lands here. The Objective section documents what the provider observed or measured: your vital signs, physical exam findings, and results from any tests performed that day. The Assessment is the provider’s interpretation of everything above, often stated as a diagnosis or a list of possible diagnoses. The Plan section lays out next steps, including tests ordered, referrals to specialists, prescriptions, and any instructions you were given.
These notes are now visible to you almost in real time. Under the 21st Century Cures Act’s information blocking rule, eight categories of clinical notes entered into an electronic health record must be immediately available through your patient portal. Providers cannot delay or block your access to this information, including test results.
Diagnoses and Procedure Codes
Behind every diagnosis your provider gives you, there’s a standardized code. The system used across all healthcare settings in the U.S. is called ICD-10-CM, maintained by the CDC. These codes translate your conditions into a universal language that insurance companies, public health agencies, and other providers can all read. A code exists for almost everything, from a sprained ankle to a specific type of diabetes.
Procedures get their own codes too. Office visits, surgeries, lab draws, and imaging studies are coded using a system called CPT, which is divided into sections covering evaluation and management, anesthesiology, surgery, radiology, pathology, and laboratory medicine. A separate set of codes covers supplies and equipment like prosthetics, orthotics, and durable medical equipment. These codes appear on your records and on the billing statements you receive after care. They don’t determine whether your insurance covers a service, but they’re the foundation of how claims get processed.
You’ll sometimes notice modifiers attached to these codes. These add context, like indicating that a procedure was performed on the left side versus the right, or that a service was distinct from another one billed the same day.
Medications and Prescriptions
Your medication list is one of the most actively maintained parts of your record. It includes current prescriptions, dosages, how often you take them, the prescribing provider, and the date each medication was started or stopped. Many systems use a standardized drug naming system called RxNorm to ensure consistency, so the same medication isn’t listed under three different names across different pharmacies and providers. Over-the-counter medications, vitamins, and supplements are also supposed to appear here if you’ve reported them. Allergies and adverse drug reactions have their own dedicated section, often flagged prominently so that any new prescription gets automatically checked against known sensitivities.
Lab Results, Imaging, and Test Reports
Every blood draw, urine sample, biopsy, X-ray, MRI, and CT scan generates a report that becomes part of your record. Lab results typically show the value measured, the reference range for what’s considered normal, and whether your result falls outside that range.
Imaging reports follow their own structure. The body of the report describes what the radiologist saw in detail, while a separate section called the “impression” gives the radiologist’s bottom-line interpretation. These two sections don’t always contain identical information. One study of radiology reports found that 36% of pulmonary nodules documented in the detailed findings section were not mentioned in the impression. This matters because the referring physician often reads only the impression. If you’re reviewing your own imaging reports, reading both sections gives you a more complete picture.
Immunization Records
Your vaccination history is tracked with a level of detail that goes well beyond which shots you received. A complete immunization entry includes the specific vaccine product, the manufacturer, the lot number, the expiration date of the vial, the date the vaccine was given, the dose volume, the route of administration (injection vs. oral, for instance), and the site on the body where it was administered. It also records whether a vaccine information statement was provided to you and the date you received it. If you declined a vaccine or had a medical reason not to receive one, that refusal or contraindication is documented along with the date and reason.
Surgical and Procedure History
Any procedure you’ve undergone, whether in a hospital, surgical center, or office setting, generates its own documentation. This includes operative reports that describe what the surgeon did step by step, anesthesia records, pathology results from any tissue removed, and post-procedure notes. Hospital inpatient procedures are coded separately from outpatient ones using a system called ICD-10-PCS. Your record also carries a running list of your past surgeries and major procedures, which new providers rely on when making treatment decisions.
What’s Not in Your Standard Record
One notable exception is psychotherapy notes. These are the private notes a mental health professional writes during or after a counseling session to document or analyze the conversation. By law, psychotherapy notes must be kept separate from the rest of your medical record, and they receive special protection. Your provider generally cannot share them with anyone, including other healthcare providers, without your written authorization. You don’t even have an automatic right to access them under federal privacy law.
It’s worth knowing what psychotherapy notes are not. They don’t include your diagnosis, treatment plan, symptoms, prognosis, progress updates, medication details, session start and stop times, or frequency of treatment. All of that information does go into your regular medical record and is accessible to you. Psychotherapy notes are specifically the therapist’s private analysis of what was discussed in session.
Your Right to Access These Records
Federal law gives you the right to request and receive a copy of nearly everything in your medical record. Once you submit a request, your provider has 30 calendar days to respond. If the records are archived offsite or otherwise hard to retrieve, they can extend that deadline by one additional 30-day period, but they must notify you in writing during the first 30 days explaining the delay and giving you a specific date. Only one extension is allowed per request. If access is denied for any reason, you must receive a written explanation.
For electronic records, the shift has been even more dramatic. Since the Cures Act took effect in April 2021, clinical notes and test results entered into an electronic system must be available to you through your portal without delay. You no longer need to formally request most of this information; it appears automatically.
How Long Records Are Kept
There’s no single federal rule dictating how long providers must store your records. HIPAA requires that records be safeguarded for as long as they’re maintained, but it doesn’t set a minimum retention period. That’s left to states, and the requirements vary widely. For pediatric records, the general recommendation is to retain them for at least 10 years or until the patient reaches the age of majority plus the state’s statute of limitations for malpractice claims, whichever is longer. In practice, this can mean records from newborn care need to be kept for 20 years or more. Adult retention periods are shorter in most states but still typically range from 6 to 10 years after the last encounter.