Your medical records

A medical record contains many types of clinical documentation. The records listed below are the documents most commonly requested by patients, parents, and legal guardians. These reports often provide a comprehensive overview of a patient’s care and are routinely included when appropriate.

Immunization records

A summary of vaccines and immunizations the patient has received at Children’s Minnesota.

Discharge summary
A report completed following a hospital stay that summarizes the reason for admission, care provided, diagnoses, procedures, medications, tests, immunizations, and the plan for follow-up care after discharge.

History and physical (H&P)
A detailed report completed at the time of hospital admission. It includes the patient’s medical history, current condition, physical examination findings, family and social history, and the clinician’s assessment of the illness or condition.

Operative report
A detailed summary of a surgical procedure, including the diagnosis before and after surgery, the procedure performed, and the surgeon’s findings.

Laboratory results
Reports containing the results of laboratory tests. Please note that some results may not be immediately available, as processing times vary depending on the type of test.

Pathology reports
If tissue or specimens were collected during a procedure, a pathology report provides the laboratory’s evaluation and findings. These reports may take several days to be finalized.

Medication reconciliation
A list of the medications a patient was taking before admission and those prescribed at discharge, helping ensure continuity of care.

Consultation reports
When a specialist is asked to evaluate a patient, they document their findings, recommendations, and assessment in a consultation report focused on a specific condition or concern.

Discharge instructions
Instructions provided at the end of a hospital stay, including diagnoses, medications, dietary recommendations, activity restrictions, follow-up appointments, and other care instructions.

Outpatient visit documentation
Records from clinic, specialty, or other outpatient visits. These reports may include the reason for the visit, assessment and treatment provided, physical examination findings, medications, immunizations, tests ordered, and follow-up recommendations.