Review: The Composition & Organization of a Medical Record
Here is what we have learned from The Composition & Organization of a Medical Record:
- A medical record may be quite simple or extremely complex, containing some information handwritten by physicians hard to decipher.
- It is imperative for an abstractor to be familiar with medical terminology and diagnostic procedures to be able to abstract pertinent information from a medical record.
- The information contained in most medical records includes patient identification, referral information, biographical information, medical history, physical examination, etc.
- Forms, record notes, and summary sheets in the hospital's record may or may not contain relevant information for filling out a cancer registry abstract.
- Examples of forms, record notes, and summary sheets include, but are not limited to, admission sheet, autopsy report, cytology report, endoscopy report, and pathology report.
- Each hospital has its own procedures for organizing a medical record, and most of the time this is done by the medical records department.
- Usually, the record is organized in terms of the temporal sequence of events.
Go to the quiz if you want to test yourself on the material you learned in this section. The quiz is a self-assessment tool and no records are kept. The feedback will let you know if you have answered the questions correctly. You can take the quiz as many times as you want.