The patient’s initial diagnosis, diagnostic impression(s), or condition(s)
Any findings of assessments and reassessments
Any allergies to food
Any allergies to medications
Any conclusions or impressions drawn from the patient’s medical history and physical examination
Any diagnoses or conditions established during the patient’s course of care, treatment, or services
Any consultation reports
Diagnostic and therapeutic tests and their results obtained during the course of care, treatment, or services
The history of any operative and other high-risk procedures, including placements of implants
Any medications administered, including the strength, dose, route, date and time of administration
Any access site for medication, administration devices used, and rate of administration
The patient's response to any medication administered
Any adverse drug reactions
Any clinical summaries of treatment received from other providers, including postoperative reports