A medical procedure is any action performed on or for you as part of your healthcare. This includes surgeries, diagnostic tests, treatments, therapies, and other medical services you receive.

Your procedure history helps your healthcare team understand your treatment background, avoid unnecessary repetition, and make better decisions about your future care.

Note: Only your healthcare providers can add or update your procedure records to ensure accuracy and proper medical oversight.

 

Types of Procedures You'll See

Surgical procedures:

  • Major surgeries (heart surgery, joint replacement, tumor removal)
  • Minor surgeries (skin lesion removal, cataract surgery)
  • Biopsies and tissue sampling

Diagnostic procedures:

  • Imaging studies (X-rays, CT scans, MRIs, ultrasounds)
  • Laboratory tests (blood work, urine tests, cultures)
  • Endoscopic procedures (colonoscopy, upper endoscopy)
  • Cardiac tests (EKG, echocardiogram, stress tests)

Therapeutic procedures:

  • Physical therapy and rehabilitation
  • Injections (joint injections, vaccinations)
  • Wound care and dressing changes
  • Chemotherapy and radiation therapy

Preventive procedures:

  • Screening tests (mammograms, colonoscopies, Pap smears)
  • Preventive treatments (dental cleanings, eye exams)

Understanding Your Procedure Information


Basic information:

  • Procedure name: The medical name for what was done
  • Category: The type of procedure (surgical, diagnostic, therapeutic)
  • Body site: What part of your body was involved
  • Status: Whether it's completed, in progress, or stopped

Timing and results:

  • When performed: The date or time period when the procedure was done
  • Reason: Why the procedure was performed
  • Outcome: The result of the procedure
  • Complications: Any problems that occurred (if any)
  • Follow-up: What you need to do after the procedure

Care team information:

  • Performers: Who performed the procedure and their roles
  • Location: Where the procedure was performed
  • Devices: Any equipment or devices used or implanted

 

How to Use This Information

Review regularly:

  • Check that all procedures you've had are listed
  • Note any procedures you don't recognize or remember
  • Pay attention to follow-up requirements and outcomes
  • Look for patterns in your treatment history

Share with healthcare providers:

  • Inform new doctors about significant procedures you've had
  • Share procedure information during emergency visits
  • Mention any implanted devices before MRIs or other procedures
  • Provide complete procedure history to specialists

Stay engaged in your care:

  • Follow all post-procedure instructions
  • Attend all scheduled follow-up appointments
  • Report any complications or concerns promptly
  • Ask questions about procedure outcomes and next steps

 

Questions to Ask Your Healthcare Team

Before a procedure:

  • "What exactly will be done during this procedure?"
  • "Why do I need this procedure?"
  • "What are the risks and benefits?"
  • "How should I prepare?"
  • "What should I expect during recovery?"

After a procedure:

  • "How did the procedure go?"
  • "What were the results or findings?"
  • "What do I need to do for follow-up care?"
  • "When should I expect to feel better?"
  • "What symptoms should I watch for?"

About your procedure history:

  • "How do my past procedures affect my current treatment options?"
  • "Do I need any repeat procedures or follow-up tests?"
  • "Are there any long-term effects I should know about?"
  • "How often should I have certain screening procedures?"

Your procedure history is a valuable record of your healthcare journey. Use it to stay informed and actively participate in your care decisions.