About medical records, each institution presents a design of their own with a series of paragraphs or chapters derived from a model that is considered “classic” or “universal”. Below are the necessary data containing medical records widely used, this list is not exclusive of all the possible content; it has been created on the understanding and awareness of the reader in the importance and seriousness of this document:

Groups Subgroups / Data
Practice Information

•    Type
•    Company name

•    Address
•    License

Demographic Information

•    Patient name
•    Gender
•    Date of birth (age)
•    Place of birth
•    Nationality
•    Address
•    Marital status

•    Education level
•    Profession or occupation
•    Occupation status

•    Religion
•    Legal guardian (minors or a social disabled person)
•    Contact methods (phone, email, other)

Background

•    Family history
•    Personal not pathological
•    Type of living or housing

•    Habits
•    Previous occupations
•    Use of free time
•    Immunizations
•    Awareness of their illness

Background
Gynecology –Obstetrics (unique to women)

•    First menstrual period
•    Menstrual Cycle

•    Sexually active start date
•    Number or couples
•    Pregnancies
•    Births
•    Abortions
•    Cesareans
•    Birth control method
•    Sexually transmitted diseases
•    Menopause
•    Papanicolaou
•    Breastfeeding

Andrology Background
(unique to men)
•    Circumcision
•    Cryptorchidism
•    Urinary incontinence
•    Sexually active start date
•    Number of sexual partners
•    Sexually transmitted diseases
•    Disorder of erection
•    Andropause
Pathological background

•   Infectious and contagious diseases
•   Exanthemata’s disease

•    Chronic – degenerative diseases
•    Allergies
•    Surgical
•    Traumatically events
•    Transfusion
•    Convulsive symptoms
•    Addictions
•    Previous hospitalizations

Chief complaint •    Circumstances of the consultation
•    Main symptom or discomfort
•    Accompanying symptoms
•    Para-clinic studies
•    Therapeutic used
Clinical interrogation by apparatus and systems

•    Respiratory System
•    Digestive System
•    Cardiovascular system
•    Kidney and Urinary System
•   Genital Tract
•    Endocrine system

•    Lymphatic and hematopoietic system
•    Skin and appendages
•    Muscle - skeletal
•    Nervous system
•    Sense Organs
•    Psychic Sphere
•    General Symptoms

Vital Signs •    Pulse
•    Blood Pressure
•    Temperature
•    Respiratory Rate
•    Heart Rate
•    Weight
•    Height
•    Body Mass Index


General Inspection

(habitus exterior)

•    Apparent age

•    State of alert and orientation
•    Integrity
•    Nutritional status
•    Facie
•    Constitution
•    Conformation
•   Attitude
•    Language
•   Abnormal movements
•    Skin characteristics
•    Cooperation
•    Clothing
•    Dressing
•    March

Physical Examination

•    Head
•    Neck

•    Thorax
•    Abdomen
•    Inguino-crural region

•    External genitalia
•    Pelvic exam
•    Rectal exam
•    Extremities
•    Spinal Column
•    Neurological Examination

Depending on the medical specialty or attention required by the patient, the medical record may contain additional information; each one of the specialties of medicine may require more information which must be contained in the medical record of the patient.

This information should be complemented with detailed as possible description, specific diagnostics, plans and treatments. Information will help with the process of health improvement of the patient. The dossier is a form of communication with the medical team, which has been, is and will be in charge of the patient's care, these documents are almost always the only mean of communication with the rest of the staff that is in different shifts and different specialties but serve a same patient.