Free Hospital Medical Records Template
Hospital Medical Records
PATIENT INFORMATION
|
Field |
Details |
|---|---|
|
Patient Name |
Dexter Dicken |
|
Date of Birth |
01/15/2050 |
|
Gender |
Male |
|
Address |
Boise, ID 83701 |
|
Contact Number |
222 555 7777 |
|
Emergency Contact |
Sarah Dicken (Spouse) |
|
Emergency Contact Number |
222 555 7777 |
HOSPITAL DETAILS
|
Field |
Details |
|---|---|
|
Hospital Name |
[YOUR COMPANY NAME] |
|
Hospital ID |
HOSP-2090-4587 |
|
Attending Physician |
Dr. [YOUR NAME] |
|
Department |
Cardiology |
|
Date of Admission |
11/28/2090 |
|
Date of Discharge |
12/02/2090 |
MEDICAL HISTORY
|
Condition |
Details |
|---|---|
|
Known Allergies |
Penicillin |
|
Chronic Conditions |
Hypertension, Type 2 Diabetes |
|
Past Surgeries |
Appendectomy (2068), Knee Replacement (2085) |
|
Family Medical History |
History of cardiovascular disease in paternal lineage |
CURRENT MEDICAL RECORDS
Vital Signs:
|
Measurement |
Value |
|---|---|
|
Heart Rate |
85 BPM |
|
Blood Pressure |
140/90 mmHg |
|
Temperature |
98.6°F |
|
Respiratory Rate |
18 breaths per minute |
Diagnosis:
|
Field |
Details |
|---|---|
|
Primary Diagnosis |
Acute Myocardial Infarction |
|
Secondary Diagnosis |
Hyperlipidemia |
Medications:
|
Medication Name |
Dosage |
Frequency |
|---|---|---|
|
Atorvastatin |
20 mg |
Once daily |
|
Aspirin |
81 mg |
Once daily |
|
Metoprolol |
50 mg |
Twice daily |
LAB TESTS AND RESULTS
|
Test Name |
Date |
Result |
Reference Range |
|---|---|---|---|
|
Lipid Panel |
11/29/2090 |
Elevated LDL: 190 mg/dL |
LDL: <100 mg/dL |
|
Troponin |
11/29/2090 |
0.8 ng/mL |
<0.03 ng/mL |
|
Complete Blood Count |
11/29/2090 |
Normal |
Normal Ranges |
TREATMENT PLAN
|
Treatment |
Start Date |
End Date |
Notes |
|---|---|---|---|
|
Percutaneous Coronary Intervention (PCI) |
11/29/2090 |
11/29/2090 |
Successful stent placement |
|
Lifestyle Modification Counseling |
12/01/2090 |
Ongoing |
Focus on diet and exercise |
NOTES AND OBSERVATIONS
The patient responded well to treatment. Discharge instructions provided, including medication adherence, dietary changes, and follow-up appointments. Monitoring required for blood pressure and cholesterol levels.
