Composition of a Medical Record

A medical record contains a variety of reports detailing a patient’s history and care at a medical facility. Each reporting facility has its own procedures for organizing a medical record. Most of the time this will be done by the medical records department, also known as the Health Information Department. Paper medical records with handwritten entries have largely been replaced by the Electronic Health Record (EHR). The EHR is an electronic (digital) collection of medical information about a person. An EHR includes information about a patient’s health history, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans. A patient’s EHR can be seen by all healthcare providers who are taking part in their care and can be used to help make treatment and other supportive recommendations. EHR may also be called electronic medical record (EMR) (https://www.cancer.gov)

Information in a medical record may include

• Patient Identification
• Referral Information
• Biographical Information
• Medical History
• Physical Examination
• Radiology/Diagnostic Imaging Reports
• Laboratory Reports
• Pathology Reports (including cytology and autopsy reports)
• Treatment Reports
• Physician Consult Notes
• Progress Notes
• Social Work Notes
• Discharge Summary
• Follow-up Reports
• Death certificate

A collegiate level educational background that includes medical terminology is required for the cancer registry field. Being familiar with common medical prefixes, suffixes and root words will help a cancer registrar abstract a cancer case. Common diagnostic tests and procedures should also be familiar to cancer registrar in order to properly complete an abstract or follow up with a physician to see if a procedures was performed.

Updated: December 28, 2023