Merck Manual

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What Should Be in a Personal Medical Record?

What Should Be in a Personal Medical Record?

  • Significant or chronic medical problems

  • Current drug regimen

  • Other treatments

  • Allergic reactions to drugs

  • Hospitalizations, including operations (dates, location, attending doctor’s name, and diagnoses)

  • Laboratory and other test results

  • Family medical history

  • Immunizations, including dates

  • Visits to any doctor’s office (dates, reason, test results, diagnosis, and recommendations)

  • Payments made

  • Copies of advanced directives