The medical record includes information that the patient has provided about his or her past medical history, history of present complaint, and symptoms.
It records the patient's vital signs at the time of treatment, and the physician's (or other professional's) observations from the physical exam.
The record includes information about all the diagnostic tests that have been carried out. It may include the actual results from a lab test or x-ray, or simply the physician's reading or interpretation of those diagnostic tests.
Finally, the record reports the patient's diagnosis, the medical or surgical interventions performed, the outcome of the treatment and any future treatment plans for this patient (such as prescriptions to be filled, or follow-up appointments).