Health Information Personnel Practice Test

Which of the following is NOT a typical inclusion in a patient's health record or chart?

1. The patient’s medical history

2. Doctor’s orders and notes

3. Results of laboratory tests

4. Nurse’s notes

5. Patient's employment history

6. Diagnoses

The correct answer is: Patient's employment history

The patient’s employment history is not typically included in a patient's health record or chart. Health records primarily focus on the medical and clinical information pertinent to the patient's care, which includes detailing the patient's medical history, doctor’s orders and notes, laboratory test results, nurse’s notes, and diagnoses. While a patient's employment history can provide helpful context regarding their health in certain scenarios—such as occupational health assessments—it is not a standard component of health records that directly relate to diagnoses, treatments, or clinical observations. The other elements listed are crucial for understanding a patient's health status and ongoing care.