Protected Information in the Medical Record

• Patient registration form
• Insurance information
• Consent forms
• HIPAA forms
• Health history form
• Physical examination
• Progress notes
• Laboratory reports
• Diagnostic reports (x-ray, MRI, ECG, etc.)
• Medication record
• PT, OT reports
• Homecare reports
• Hospital documents (OP, D/C, pathology reports)
• Correspondence
• Consultation reports