Medical
Records 101, Lesson 2
Components
of the Medical Record
Janabeth F. Taylor
HOSPITAL
RECORDS
Hospital records include, but are not
limited to:
Admission Information/Summary - documents date/time of admission, admitting
diagnosis. Admitting physician and other basic admission information
Discharge Summary - documents condition at time of discharge, any post discharge
instructions for lab tests, physician appointments and medications prescribed, as well as
instructions for physical activity and other treatment modalities.
Admission History and Physical - documents condition at time of admission, usually
performed by admitting physician, but sometimes deferred to a medical resident or physician
assistant. There may also be a separate document, “Physician’s Admission History and Physical”
in some health care facilities.
Physician’s Progress Notes - daily chronology of patient’s progress, often
gives rationale behind change in treatment or medication and documents physician visits.
Emergency Room Records - documents condition upon arrival, chief medical complaint
and may also include emergency room physician evaluation of any tests performed such as ultrasound,
radiology and laboratory tests. Also recommendations for referral, admission and/or discharge are
obtained here.
Consultation Reports (Physician and other professional.)
documents evaluation and recommended treatment
by physicians, and other health care providers asked to consult in reference to patient care.
Physician’s Orders - documents date and time of treatments
and medications ordered by treating physicians. These are to be signed by the physician ordering,
even if a telephone order or phone/verbal order given to a nurse.
Operating Room Records and Report (Physician, Nursing and Anesthesia Record) -
documents procedure performed, surgeons, nurses and anesthesia personnel present during surgery.
Also documents patient condition before, during and after surgery. Some hospitals document post
operative care in the “PAR” (post anesthesia recovery) record.
Laboratory Reports - documents results of tests performed in the laboratory.
Includes not only blood and urine tests, but also cultures of tissue and microscopic exam of tissue.
Graph Sheets - documents basic vital signs and other basic functions such as
urinary and intestinal elimination. Some graphic sheets also document dietary and fluid intake.
I and O record - documents fluid and solid intake and output on a daily basis. Usually
tallied on a daily basis, but may be recorded with each shift (two to three times a day)
Treatment Sheets - documents all manner of treatments such as wound care, hot and
cold therapy not given in physical therapy, etc.
Medication Sheets - documents medications given. PRN medication is given on an
“as needed” basis and may be listed separately from regularly scheduled medications.
Xray/Radiologist Reports - documents radiologist’s impression of radiology
tests. Will also contain name of ordering physician.
Physical Therapy Records - documents treatments/therapy given in the Physical
therapy department as well as the patients response to therapy.
Speech Therapy Records - documents therapy given by speech pathologist.
Occupational Therapy Records - documents therapy given by occupational therapist.
May be included as part of physical therapy records in some institutions.
Nurse’s Notes/Nursing Progress Notes - Chronological
documentation of patient’s condition, physician visits, change in condition and treatments given
as well as patient responses. Usually written in longhand, but more and more frequently are seen as
a computerized record.
Nursing Care Plans - Each patient has a general plan of care, and the foundation
is determined by the policy of the health care facility. However, generally the nursing care plan
covers all treatments, medications and therapies ordered for the patient. Goals are also stated for
patient care.
Interdisciplinary/Multidisciplinary Progress Notes (Not utilized in all
facilities.) - documents progress of each therapeutic department in chronological order, rather than
a separate progress note maintained by each department. May include notes made by more than one
department, such as speech, physical and occupational therapies.
Other records found but not consistently maintained by all facilities may include:
Records/Treatment Logs
• Treatment
Records, Nursing Treatment Records (Sometimes in with the medication records; sometimes listed
separately.)
• Physical
Therapy
• Speech
Therapy
• Occupational
Therapy
• Rehabilitation
Therapy, Restorative Services
• Recreational
Therapy, Activity Therapy or Service
• Any
other form of therapy records
• Visiting
Nursing or Home Care Nursing Records
• Records
from Independent Medical Laboratories
• Records
from Independent Radiology and Nuclear Medicine Services
EMERGENCY
SERVICE RECORDS:
• Ambulance
Records (EMS
Emergency
Medical Service) - these records may be maintained by either an independent EMS service or a
municipal fire department, or hospital EMS service.
• Emergency
Room Records (These are often not part of the hospital records, where the emergency room is operated
by an independent contractor.)
In some situations, the records of emergency response personnel such as the local police
and rescue portions of the fire department will also apply and will be separate from other EMS
records, and a separate request for each entity will be required in order to obtain all records.
Janabeth F. Taylor,
R.N., R.N.C. has a degree in Nursing from Oklahoma State University and
Litigation Paralegal Certificate from the University of Oklahoma Law Center. She was a
nursing instructor for ten years and has been a medical legal consultant since 1990. Ms. Taylor is
currently President/Owner of Attorney’s Medical Services, Inc. in Corpus Christi, TX.
In 2002 she was
named the Association of Trial Lawyers of America’s Paralegal of the Year. She provides litigation
support for attorneys across the United States and specializes in case reviews and Internet
information resources. Her website is http://www.attorneysmedicalservices.com and her email address
is jana@
attorneysmedicalservices.com
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