SEER Training Modules

Medical Record Forms

Forms used to record information in a medical record

Following is a list of most forms, records notes, and summary sheets which may be found in your hospital's medical record. The names are self-explanatory. Some contain little or no information of interest to a tumor registrar. "Starred" (*) items are most likely to contain relevant information for filling out a cancer registry abstract.

  • *Admission Sheet
  • Anesthesia Record
  • *Autopsy (Necropsy; post Mortem) Report
  • *Chemotherapy Report
  • *Consultation Report (Request for opinions or aid from other physicians or departments)
  • *Cytology (Cytopathology) Report
  • *Death Certificate
  • *Diagnostic Radiology (X-ray) Report
  • *Discharge (Narrative) Summary
  • *Doctor's Order Sheets
  • Doctor's Progress Notes
  • Electrocardiogram (EKG) Report
  • *Electroencephalogram (EEG) Report
  • Emergency (Accident) Report
  • *Endoscopy Report
  • Graphic Reports (Temperature, Pulse, Respiration, Blood Pressure)
  • Recovery (Post-Anesthesia) Room Report
  • Request to Blood Bank Report
  • *Hematology Report
  • *History and Physical Examination
  • *Immunotherapy Report
  • Informed Consent to Treatment
  • Intake-Output Chart (measured liquids)
  • *Laboratory Reports
  • *Medical Record Data Sheet (Face or Cover Sheet)
  • *Medication Record
  • *Nuclear Medicine Report (Diagnostic Imaging / Scans)
  • *Nuclear Medicine Report (Radio-Isotope Exposure Record)
  • *Nurse's Notes
  • Occupational Therapy
  • *Operation (Surgery) Report
  • *Outpatient Clinic Record
  • *Pathology (Histology) Report
  • Physical Therapy Report
  • *Protocol Study Report
  • *Radiation Therapy Summary
  • *Referral Letters (From local medical doctor's or other institutions)
  • *Serology Report
  • *Tumor Board Summary Serology Report