Understanding Medical Records: A Guide for Naval Health Clinic Cherry Point Patients

Photo By Thomas Cieslak | Medical records are an essential part of your healthcare to ensure everything that happens when you receive care, whether during a routine outpatient visit or a hospital stay, is documented accurately. Understanding what medical records are, what they include, and how you can access and manage them is key to taking control of your health.  

CHERRY POINT, NORTH CAROLINA, UNITED STATES

02.05.2026

Courtesy Story

Naval Health Clinic Cherry Point

Medical records are an essential part of your healthcare to ensure everything that happens when you receive care, whether during a routine outpatient visit or a hospital stay, is documented accurately. Understanding what medical records are, what they include, and how you can access and manage them is key to taking control of your health.

The Basics of Medical Records

Medical records are detailed documents where healthcare professionals record all aspects of your care. They serve as a comprehensive history of your health and are used to ensure you receive the best possible treatment. These records include both personal and medical information.

What Medical Records Contain

Medical records include two main types of information: 1.Personal Information: • Name, date of birth, and contact details. • Social Security number, driver’s license, or other identification numbers. • Insurance plan details and appointment history.

2. Medical Information: • Notes from doctor visits, including the reason for the visit and findings from physical exams. • Vital signs, such as blood pressure, heart rate, and temperature. • Medications, lab results, and imaging (e.g., X-rays, MRIs). • Diagnoses, treatment plans, and follow-up instructions. • Orders from doctors, such as prescriptions or referrals.

Who Contributes to Medical Records

Healthcare professionals contribute to your medical records based on their role on your healthcare team: • Administrative Staff: Enter personal and administrative data, such as contact information and appointment details. • Nursing Staff and Medical Assistants: Record vital signs, medications, and intake information, such as the reason for your visit and health screening questionnaires. For hospitalized patients, they also document nursing checks, administered medications, and other care provided. • Doctors and Providers: Document clinical evaluations, including the reason for the visit or inpatient stay, history, physical exam findings, diagnoses, treatment plans, and medical decision-making. They also enter orders for medications, tests, or procedures.

Access to Medical Records and Safeguards

Access to medical records is strictly controlled to protect your privacy. Only authorized medical staff can access your records, and they must have a valid reason to do so as part of their duties related to your care. • HIPAA and Privacy Rule Training: All personnel accessing medical records are trained in the Health Insurance Portability and Accountability Act (HIPAA) and Privacy Rule regulations. They can only view the parts of your record necessary to accomplish what is needed for their role in your care. • MHS Genesis Safeguards: For patients in the Military Health System (MHS), the MHS Genesis system includes an additional safeguard. When a staff member accesses a record, a pop-up box requires them to select their relationship to the patient (e.g., covering provider, emergency access, peer review) before proceeding. • Technology: Systems like MHS Genesis include features to track and monitor who accesses your records and why.

Your Rights as a Patient

As a patient, you have important rights regarding your medical records:

1. Access: You have the right to view and obtain a copy of your medical records.
2. Accuracy: You can request corrections if you find errors in your records.
3. Privacy: Your records are protected by law, and only authorized individuals can access them.

What You Can See in Your Medical Records

Through the MHS Genesis Patient Portal or similar systems, you can access:

• Complete clinical notes from your visits. • Vital signs, lab results, and imaging reports. • Medications and prescriptions. Immediate Access to Results: As part of a recent change in DHA policy, all clinical results, including lab tests and imaging reports, are now immediately released to the patient portal as soon as they are available. This means you may see your results before your doctor has had a chance to review and interpret them.

Interpreting Results in the Patient Portal

With the immediate release of clinical results, it is important to approach your records thoughtfully. Here are some tips to help you navigate this change:

1. Stay Calm: Medical test results often include technical terms or numerical values that can be difficult to interpret without medical training. Seeing these results without context may cause confusion or unnecessary worry.
2. Wait for Your Doctor’s Input: Even if you see your results in the portal, your doctor will contact you to discuss their interpretation and what the results mean for your health. Be patient and allow them time to review your case.
3. Take Notes: Write down any questions you have about your results so you can discuss them with your doctor during your next appointment or follow-up.
4. Use Trusted Resources: If you want to research your results, use reliable medical resources, such as those provided by the DHA or other reputable health organizations. Avoid jumping to conclusions based on unverified online sources.

Reviewing and Managing Your Medical Records

It’s a good idea to review your medical records regularly to ensure they are accurate. Here’s how you can do it:

1. When to Review: • At least once a month. • After every clinical visit or hospital stay. • Whenever new test results or imaging reports are released.
2. How to Review: • Log in to your patient portal (e.g., MHS Genesis Patient Portal). • Review the clinical notes, test results, and other information. • If you find an error, submit a request to the medical records representative at your healthcare facility.

Final Thoughts

Your medical records are a powerful tool for managing your health. By understanding what they include, who can access them, and how to review them, you can take an active role in your healthcare. The immediate release of clinical results to the patient portal is a step toward greater transparency, but it also requires patients to approach their results with caution and rely on their healthcare providers for interpretation and guidance.

Regularly checking your records ensures they are accurate and up to date, which helps you and your healthcare team make the best decisions for your care. If you have questions about your medical records or need help accessing them, don’t hesitate to reach out to your healthcare provider. They are there to support you every step of the way.

• Date Taken: 02.05.2026
• Date Posted: 02.05.2026 10:24
• Story ID: 557503
• Location: CHERRY POINT, NORTH CAROLINA, US