Emergency room physician—More than 40 percent of patients who are admitted to the hospital are admitted through the emergency room.1 The emergency room physician sees you and then documents your diagnosis and orders for your treatment in your record. If you are admitted to the hospital, you will have many other clinicians caring for you.

Primary care physician (PCP)— If you are admitted to the hospital, your PCP, also known as your “attending physician,” is generally responsible for coordinating the care among any other physicians or specialists providing evaluations or treatment to you during the hospital stay. Your PCP is also usually the physician responsible for documenting the order for your discharge from the hospital.

Surgeon—If you are being admitted to the hospital for a surgical procedure, your attending physician may be your surgeon. Your surgeon is responsible for documenting the reason for your surgery, explaining risks of the procedure, and obtaining informed consents from you. If you have other health problems in addition to the condition for which you are receiving surgery, the surgeon may order evaluations from specialist physicians. The surgeon is also responsible for documenting, in detail, the surgical procedure that he performs on you. This document is known as the “operative report.”

Specialist physician—The specialist physician is also known as the “consulting physician.” The consultant is an expert in the area where you are suspected to have a problem. Examples of specialists include cardiologists, neurologists, and endocrinologists. Generally, a specialist physician will evaluate you in response to a request by your primary care physician (PCP). The specialist will document his evaluation in your medical record.

Unit nurses—Present on all hospital units 24 hours a day, nurses are responsible for monitoring your vital signs regularly and implementing certain physician orders such as medication administration. Nurses provide a significant amount of documentation in your record

Radiologist—The radiologist is the physician who reads and interprets your x-rays and other types of images. The radiologist is responsible for reading and interpreting each of your tests and then documenting his impression or diagnosis in a formal report that becomes part of your medical record.

Pathologist—Documentation from a pathologist will only appear on your record if you need laboratory analysis done on tissue or body fluid removed during a surgical procedure. That tissue or fluid is sent to the pathologist, who is responsible for examining for any abnormalities. the pathologist documents his assessment in your record.

Every person on your healthcare team needs to know as much as he can about all of your healthcare diagnoses and treatments completed by other members of your team. Your medical record is the vital instrument containing all of this healthcare data about you.