Which of the following is not found in the patient's medical record?

September 25, 2025 •

4 min read

Over 90% of healthcare organizations now use electronic health records, yet many patients are unaware of what their medical files contain. Understanding the specific components and deliberate omissions is crucial for anyone wondering which of the following is not found in the patient's medical record?

Quick Summary

Several types of personal and legal documents are intentionally excluded from a patient's medical record to maintain its objective, clinical nature. This typically includes a living will, financial information, and subjective personal remarks by staff.

Key Points

Living Wills Are Excluded: Advanced directives, such as a living will, are legal documents and are not typically stored within the clinical patient medical record.
Excluding Non-Clinical Data: Financial details, such as patient ledger cards, are administrative and not considered part of the medical record's clinical component.
Protecting Privacy and Privilege: Legal information, including correspondence with attorneys regarding potential claims, is kept separate from the patient's chart to maintain confidentiality.
Maintaining Objective Records: Subjective or derogatory remarks about a patient, another provider, or prior treatment are strictly prohibited to ensure the record remains objective and professional.
Incident Reports are Separate: Documentation of adverse events, like incident reports, are separate from the patient’s medical record; only the medically pertinent facts should be recorded.
Purpose of the Medical Record: A medical record is meant to be a factual, objective history of a patient's health and treatment to ensure continuity of care, not a diary or a place for personal opinions.

Understanding the Purpose of a Medical Record

A patient's medical record is a legal document and a critical tool for healthcare providers. Its primary purpose is to chronicle the patient's health history, treatments, and outcomes to ensure continuity of care and facilitate communication among the medical team. The information contained must be factual, objective, and clinically relevant. This strict focus is why certain types of information, including those listed in a multiple-choice format, are excluded.

What Is Typically Included in a Medical Record?

To understand what is omitted, it is helpful to first examine what is expected to be present. The standard medical record is a comprehensive compilation of a patient's health journey. This typically includes:

Patient Demographics: Personal information such as name, address, date of birth, and contact information.
Medical History: A detailed account of past illnesses, surgeries, hospitalizations, and family medical history.
Immunization Records: A log of all vaccinations and dates administered.
Operative Reports: Detailed reports of any surgical procedures performed.
Physician's Orders: Instructions from the doctor to the healthcare staff.
Progress Notes: Notes from physicians, nurses, and other specialists detailing the patient's condition, treatment, and progress.
Diagnostic Test Results: Lab results, imaging reports, and other diagnostic data.
Medication Administration Records: A history of medications prescribed and administered.
Referral Letters: Correspondence between healthcare providers regarding patient care.

The Answer: What Isn't in a Medical Record?

Based on the typical multiple-choice question format, a living will is a document that is not found in the patient's medical record. While a healthcare provider may be made aware of a patient's advanced directives, the legal document itself is not part of the clinical file. This is because a living will is a legal document outlining end-of-life wishes, not a clinical record of medical care received.

Other Exclusions and Why They're Omitted

Beyond legal documents like a living will, other types of information are purposefully kept out of medical records to maintain a clear and objective account of patient care. Excluding this information helps prevent legal complications and ensures that clinical decisions are based solely on factual medical information.

Financial and Billing Information: This includes ledger cards, billing statements, and insurance details. These are administrative and financial records, not part of the patient's clinical care history.
Subjective Personal Opinions: Any personal remarks, speculations, or disparaging comments about a patient or other medical staff are strictly forbidden. Documentation must be objective and based on professional judgment.
Privileged Legal Information: Communication with legal counsel regarding malpractice claims or incident reports should be kept separate from the medical record to protect legal privilege.
Derogatory Remarks: Negative comments about a patient's character, lifestyle, or prior treatment by another physician are inappropriate and have no place in a professional medical document.

Comparison of Included vs. Excluded Information


Included in Medical Record	Excluded from Medical Record	Rationale
Immunization Records	Living Will (Advanced Directive)	Legal document vs. clinical care record.
Operative Reports	Patient Ledger/Billing Records	Clinical history vs. financial information.
Diagnostic Test Results	Subjective Opinions on Patient's Character	Factual medical data vs. unprofessional judgment.
Physician Progress Notes	Legal Correspondence	Clinical observation vs. privileged legal information.

The Importance of Accurate Medical Records

Accurate and complete medical records are essential for several reasons, and understanding what should and should not be included is part of this accuracy. The record protects both the patient and the healthcare provider. For the patient, it ensures that all providers have a consistent, comprehensive history. For the provider, it serves as a critical defense against malpractice allegations by providing an objective account of the care rendered. Any attempt to alter, falsify, or inappropriately include non-clinical information can have serious legal and ethical consequences.

Ensuring Patient Privacy and Information Security

This segregation of information also relates to patient privacy and security under regulations like the Health Insurance Portability and Accountability Act (HIPAA). By limiting the medical record to only relevant clinical information, the privacy of the patient's medical data is better protected. Information like a living will, which is a legal document, is often managed separately to ensure patient autonomy and to prevent it from being inappropriately accessed or used in a way that contradicts the patient's wishes.

Visit the Department of Health & Human Services for more information on HIPAA compliance and patient privacy laws.

Conclusion

In summary, the items excluded from a patient's medical record are as important as those included. Medical records are designed to be objective, clinically focused, and factual. Legal documents like a living will, along with financial data and subjective personal comments, are intentionally omitted to uphold the integrity of the record. This practice ensures that patient care decisions are based on sound medical judgment, protects the patient's privacy, and safeguards both the patient and provider in legal matters. Knowing this distinction is key to understanding the purpose and nature of your health records.

Frequently Asked Questions

A living will is a legal document that expresses a patient's end-of-life treatment preferences, not a clinical record of care. While providers should be informed of its existence, the document itself is stored separately to maintain the medical record's objective focus on clinical facts.

No, billing, payment, and other financial records are administrative documents and are not part of the clinical medical record. This separation is crucial for maintaining the medical record's clinical integrity and objectivity.

Including subjective or derogatory comments is unprofessional and highly discouraged. Such remarks can harm the provider's credibility and be used against them in a malpractice lawsuit, as they violate the principle of objective, factual documentation.

No, incident reports detailing adverse events are typically kept separate from the medical record to protect legal privilege. Only the clinically relevant facts related to the event should be documented in the patient's chart.

Accuracy is vital for several reasons. It ensures proper continuity of care, facilitates clear communication among healthcare providers, protects the patient's privacy, and serves as a legal defense for providers against malpractice claims.

While patients can request amendments to their medical records if they believe information is incorrect, altering or removing existing documentation is subject to strict protocols. The original entry should remain visible, with corrections clearly documented.

HIPAA sets standards for the protection of patient health information. By mandating the separation of non-clinical data and limiting record contents to only necessary medical facts, HIPAA helps enforce patient privacy and security.