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
