Medical Records - Detailed Components

Sometimes, Goodbill will require specific documents if they are missing from the Medical Record visit notes.  Here, we explain the different types of documents that may be available to help us review your hospital charges.

This document is the main clinical write up of the hospital visit, and usually contains everything that Goodbill needs to review a bill.  It typically contains the following headers:

• History of Present Illness (HPI)
  This is a subjective description of the current illness or injury, and summarizes the patient’s story leading up the their visit. 

• Review of Systems (ROS)
  This is a list of questions used to identify any recent symptoms. 

• Physical Exam (PE)
  This is the results of a physical exam,  evaluating the patient’s physical appearance.

  The detailed note will usually then go on to describe the other relevant components of the visit.  However, sometimes these are missing, so Goodbill needs to request them specifically.  The following paragraphs describe these components.

This is a listing describing all the lab studies completed on the patient, and should show the date that the lab was collected, along with the findings for each (positive/negative or specific measurement)

If the patient underwent an X-Ray, CT Scan, MRI or any other imaging study, Goodbill will require this report.  It should include the details of the procedure, along with its findings.

If an electrocardiogram is used to record the electronic signals in the heart, then an EKG report will also be required by Goodbill.  This is usually either a detailed write-up of the EKG finding, or a picture/image of the EKG itself, which is a graph of vitals.

If the patient is billed for any infusion services - drugs or hydration, then Goodbill will require this document.  It should be in the detailed visit notes, but if not, Goodbill will request it specifically.   It will contain information such as drug names, dosage given, an start/stop/durations of service.

The MAR is a description of medications that were given to the patient during the stay.  It is not a list of medications that were ordered for the patient to fill after they leave the hospital, or an intake list of medications that the patient is currently taking. 

If a patient is admitted to observation (monitoring a patient’s condition), then Goodbill will require the observation notes associated with this stay.  This will likely appear as progress notes, and may be from multiple clinicians. 

If surgery was performed and anesthesia is billed, then Goodbill will need this document.  It will typically contain all drugs given during anesthesia, as well as start/stop times for these services.

This document will contain brief nurses notes from the time spent in recovery.  It will contain various sets of vital signs, or notes around how the patient was doing during the time in recovery.

If any surgery was performed, Goodbill will also require the detailed write-up from the surgeon, which explains what they did during surgery.  This includes the procedures performed, and surgical supplies used.


That’s it! As explained earlier, usually most, if not all of these reports are contained in the one document, “Detailed Visit Notes”. In the case that they are not, Goodbill will request the missing documents specifically.

It’s also worth noting that some aspects of a hospital visit, often Radiology, Anesthesia or Labs, are performed by third parties outside of the hospital billing records. In such cases, Goodbill is currently unable to support those charges.  You can read more about professional fees here.